MEDICARE: LEES MARKETPLACE 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	9903561-1703	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2163879	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1972530251
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEES MARKETPLACE INC

Provider Business Mailing Address
First Line	:	505 E 1400 N STE 110
Second Line	:
City	:	LOGAN
State	:	UT
Zip	:	84341-2459
Country	:	US
Telephone Number	:	435-774-4150
Fax Number	:	435-774-4166

Provider Business Practice Location Address
First Line	:	890 S MAIN ST
Second Line	:
City	:	HEBER CITY
State	:	UT
Zip	:	84032-2463
Country	:	US
Telephone Number	:	435-654-0414
Fax Number	:	435-657-1972

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	JONATHAN BADGER
Credential	:
Telephone Number	:	435-774-4150

Provider Enumeration Date	:	06/26/2006
Last Update Date	:	04/19/2017

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Directions to “LEES MARKETPLACE INC ” Practice Location

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