Provider Demographics
NPI:1073272852
Name:MAIN STREET DRUG & BOUTIQUE, INC.
Entity Type:Organization
Organization Name:MAIN STREET DRUG & BOUTIQUE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:GILSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:435-650-2736
Mailing Address - Street 1:PO BOX 519
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:UT
Mailing Address - Zip Code:84535-0519
Mailing Address - Country:US
Mailing Address - Phone:435-587-2302
Mailing Address - Fax:435-587-3441
Practice Address - Street 1:140 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:UT
Practice Address - Zip Code:84535-7728
Practice Address - Country:US
Practice Address - Phone:435-587-2302
Practice Address - Fax:435-587-3441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-09
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy