Provider Demographics
NPI:1528391836
Name:ASSOCIATED FRESH MARKETS INC
Entity Type:Organization
Organization Name:ASSOCIATED FRESH MARKETS INC
Other - Org Name:FRESH MARKET PHARMACY #2382
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, PHARMACY OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:SHAWNA
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
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 1:2044 HARRISON BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-0739
Practice Address - Country:US
Practice Address - Phone:801-393-5270
Practice Address - Fax:801-334-6567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-18
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
UT7442353-17033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1528391836Medicaid
2121992OtherPK