Provider Demographics
NPI:1073847323
Name:MACEYS INC
Entity Type:Organization
Organization Name:MACEYS INC
Other - Org Name:FRESH MARKET PHARMACY #2367
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:SHAWNA
Authorized Official - Middle Name:KIP
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-978-8309
Mailing Address - Street 1:PO BOX 26908
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84126-0908
Mailing Address - Country:US
Mailing Address - Phone:801-978-8225
Mailing Address - Fax:801-978-8634
Practice Address - Street 1:1825 W 4700 S
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84129-1103
Practice Address - Country:US
Practice Address - Phone:801-964-2626
Practice Address - Fax:801-965-8005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-18
Last Update Date:2021-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7442348-1703333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1073847323Medicaid
2121836OtherPK