Healthcare Provider Details

I. General information

NPI: 1215300660
Provider Name (Legal Business Name): MARKET FRESH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2015
Last Update Date: 03/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 S MAIN ST
EPHRAIM UT
84627-4017
US

IV. Provider business mailing address

475 S MAIN ST
EPHRAIM UT
84627-4017
US

V. Phone/Fax

Practice location:
  • Phone: 435-283-0340
  • Fax: 435-283-0341
Mailing address:
  • Phone: 435-283-0340
  • Fax: 435-283-0341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number9508481-1703
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2154991
Identifier TypeOTHER
Identifier State
Identifier IssuerPK

VIII. Authorized Official

Name: TYLER MERRILL
Title or Position: PRESIDENT
Credential:
Phone: 435-851-0261