Provider Demographics
NPI:1578671210
Name:LEE'S MARKETPLACE PHARMACY
Entity Type:Organization
Organization Name:LEE'S MARKETPLACE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHARI
Authorized Official - Middle Name:
Authorized Official - Last Name:BADGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-774-4150
Mailing Address - Street 1:850 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84335-2302
Mailing Address - Country:US
Mailing Address - Phone:435-563-6201
Mailing Address - Fax:435-563-4034
Practice Address - Street 1:850 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:UT
Practice Address - Zip Code:84335-2302
Practice Address - Country:US
Practice Address - Phone:435-563-6201
Practice Address - Fax:435-563-4034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2797336-1703183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========013Medicaid