Provider Demographics
NPI:1740692367
Name:A&W PHARMACY
Entity type:Organization
Organization Name:A&W PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, PIC
Authorized Official - Prefix:
Authorized Official - First Name:WADE
Authorized Official - Middle Name:
Authorized Official - Last Name:POULSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:435-738-3784
Mailing Address - Street 1:171 E MAIN ST
Mailing Address - Street 2:PO BOX 997
Mailing Address - City:DUCHESNE
Mailing Address - State:UT
Mailing Address - Zip Code:84021-0997
Mailing Address - Country:US
Mailing Address - Phone:435-738-3784
Mailing Address - Fax:435-738-3785
Practice Address - Street 1:171 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DUCHESNE
Practice Address - State:UT
Practice Address - Zip Code:84021
Practice Address - Country:US
Practice Address - Phone:435-738-3784
Practice Address - Fax:435-738-3785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-02
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
UT893201617033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1740692367Medicaid
2143889OtherPK