Provider Demographics
NPI:1356674667
Name:MACEYS INC
Entity type:Organization
Organization Name:MACEYS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:SHAWNA
Authorized Official - Middle Name:KIP
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-978-8309
Mailing Address - Street 1:1850 WEST 2100 SOUTH
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-1304
Mailing Address - Country:US
Mailing Address - Phone:801-978-8699
Mailing Address - Fax:801-978-8634
Practice Address - Street 1:5632 S 900 E
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84121-1034
Practice Address - Country:US
Practice Address - Phone:801-262-1025
Practice Address - Fax:801-262-1232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-18
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
UT7442361-17033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1356674667Medicaid
2121980OtherPK