Provider Demographics
NPI:1164795431
Name:MIDWAY PHARMACY
Entity Type:Organization
Organization Name:MIDWAY PHARMACY
Other - Org Name:MIDWAY MARKET PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER/PIC
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:435-657-0170
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:435-654-1926
Mailing Address - Fax:435-654-3039
Practice Address - Street 1:42 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDWAY
Practice Address - State:UT
Practice Address - Zip Code:84049-6313
Practice Address - Country:US
Practice Address - Phone:435-654-1926
Practice Address - Fax:435-654-3039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-17
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
UT8208474-17033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4612190OtherNCPDP PROVIDER IDENTIFICATION NUMBER
UT1164795431Medicaid
UT1164795431Medicaid