Provider Demographics
NPI:1003897356
Name:MEDICAL PLAZA PHARMACY, INC.
Entity Type:Organization
Organization Name:MEDICAL PLAZA PHARMACY, INC.
Other - Org Name:MEDICAL PLAZA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:SONDRUP
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:801-539-0231
Mailing Address - Street 1:1060 E 100 S
Mailing Address - Street 2:SUITE L-2
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1501
Mailing Address - Country:US
Mailing Address - Phone:801-539-0231
Mailing Address - Fax:801-539-0350
Practice Address - Street 1:1060 E 100 S
Practice Address - Street 2:SUITE L-2
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1501
Practice Address - Country:US
Practice Address - Phone:801-539-0231
Practice Address - Fax:801-539-0350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-11
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6075676-1703333600000X
UT9120628-1703333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========000Medicaid