Provider Demographics
NPI:1487192621
Name:MAPLE MOUNTAIN PHARMACY INC.
Entity Type:Organization
Organization Name:MAPLE MOUNTAIN PHARMACY INC.
Other - Org Name:MAPLE MOUNTAIN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-885-1147
Mailing Address - Street 1:724 S 1600 W
Mailing Address - Street 2:
Mailing Address - City:MAPLETON
Mailing Address - State:UT
Mailing Address - Zip Code:84664-4347
Mailing Address - Country:US
Mailing Address - Phone:801-515-6048
Mailing Address - Fax:
Practice Address - Street 1:724 S 1600 W
Practice Address - Street 2:
Practice Address - City:MAPLETON
Practice Address - State:UT
Practice Address - Zip Code:84664-4347
Practice Address - Country:US
Practice Address - Phone:801-515-6048
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-08
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8359109-1703333600000X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2167468OtherPK