Healthcare Provider Details

I. General information

NPI: 1457603037
Provider Name (Legal Business Name): MAPLE MOUNTAIN PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2012
Last Update Date: 04/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

724 S 1600 W
MAPLETON UT
84664-4342
US

IV. Provider business mailing address

724 S 1600 W
MAPLETON UT
84664-4342
US

V. Phone/Fax

Practice location:
  • Phone: 801-515-6048
  • Fax: 855-848-5748
Mailing address:
  • Phone: 801-515-6048
  • Fax: 855-848-5748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number8359109-1703
License Number StateUT

VII. Legacy identifiers

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

# 1
Identifier1457603037
Identifier TypeMEDICAID
Identifier StateUT
Identifier Issuer
# 2
Identifier2137217
Identifier TypeOTHER
Identifier State
Identifier IssuerPK

VIII. Authorized Official

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