MEDICARE: FAMILY PLAZA PHARMACY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	6732558-1703	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2099816	OTHER		PK

General Provider Information

NPI Number	:	1831171941
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY PLAZA PHARMACY INC

Provider Business Mailing Address
First Line	:	3570 W 9000 S
Second Line	:	STE 150
City	:	WEST JORDAN
State	:	UT
Zip	:	84088-8869
Country	:	US
Telephone Number	:	801-569-0175
Fax Number	:	801-569-6941

Provider Business Practice Location Address
First Line	:	3570 W 9000 S
Second Line	:	STE 150
City	:	WEST JORDAN
State	:	UT
Zip	:	84088-8869
Country	:	US
Telephone Number	:	801-569-0175
Fax Number	:	801-569-8941

Authorized Official
Title or Position	:	OWNER
Name	:	SHANE JENSEN
Credential	:	PHARMD
Telephone Number	:	801-569-0175

Provider Enumeration Date	:	11/15/2005
Last Update Date	:	08/12/2016

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Directions to “FAMILY PLAZA PHARMACY INC ” Practice Location

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