Provider Demographics
NPI:1891028106
Name:ASSOCIATED FRESH MARKETS INC
Entity Type:Organization
Organization Name:ASSOCIATED FRESH MARKETS INC
Other - Org Name:FRESH MARKET PHARMACY #2378
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 1:135 E MAIN ST
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-2407
Practice Address - Country:US
Practice Address - Phone:801-756-2411
Practice Address - Fax:801-756-6824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-18
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
UT7442349-17033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1891028106Medicaid
2121985OtherPK