Provider Demographics
NPI:1558406181
Name:VILLAGE PANTRY #9
Entity Type:Organization
Organization Name:VILLAGE PANTRY #9
Other - Org Name:ART CITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:801-489-5618
Mailing Address - Street 1:405 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84663-2252
Mailing Address - Country:US
Mailing Address - Phone:801-489-5618
Mailing Address - Fax:
Practice Address - Street 1:405 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:UT
Practice Address - Zip Code:84663-2252
Practice Address - Country:US
Practice Address - Phone:801-489-5618
Practice Address - Fax:801-489-0441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
UT13236317033336C0003X, 3336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2099740OtherPK
0964090001Medicare NSC