Provider Demographics
NPI:1083948210
Name:PARK CITY MARKET INC
Entity Type:Organization
Organization Name:PARK CITY MARKET INC
Other - Org Name:THE MARKET PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH, MBA
Authorized Official - Phone:435-645-7139
Mailing Address - Street 1:PO BOX 26417
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84126-0417
Mailing Address - Country:US
Mailing Address - Phone:801-978-8225
Mailing Address - Fax:801-978-8634
Practice Address - Street 1:1500 SNOW CREEK DR
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060-7506
Practice Address - Country:US
Practice Address - Phone:435-645-7916
Practice Address - Fax:435-655-7019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-21
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6957464-17033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4611706OtherNCPDP PROVIDER IDENTIFICATION NUMBER
UT870655253003Medicaid