Healthcare Provider Details

I. General information

NPI: 1487192621
Provider Name (Legal Business Name): MAPLE MOUNTAIN PHARMACY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2017
Last Update Date: 02/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

724 S 1600 W
MAPLETON UT
84664-4347
US

IV. Provider business mailing address

724 S 1600 W
MAPLETON UT
84664-4347
US

V. Phone/Fax

Practice location:
  • Phone: 801-515-6048
  • Fax:
Mailing address:
  • Phone: 801-515-6048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number8359109-1703
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL JOHNSON
Title or Position: OWNER/PRESIDENT
Credential:
Phone: 801-885-1147