Provider Demographics
NPI:1003898545
Name:APOTHECARY SHOPPE, INC
Entity Type:Organization
Organization Name:APOTHECARY SHOPPE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:DEMASS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:801-521-6353
Mailing Address - Street 1:82 S 1100 E
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1686
Mailing Address - Country:US
Mailing Address - Phone:801-521-6353
Mailing Address - Fax:801-521-6390
Practice Address - Street 1:82 S 1100 E
Practice Address - Street 2:SUITE 104
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1686
Practice Address - Country:US
Practice Address - Phone:801-521-6353
Practice Address - Fax:801-521-6390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-18
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6895933-1703333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========003Medicaid