Healthcare Provider Details

I. General information

NPI: 1073272852
Provider Name (Legal Business Name): MAIN STREET DRUG & BOUTIQUE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2021
Last Update Date: 12/09/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 S MAIN ST
MONTICELLO UT
84535-7728
US

IV. Provider business mailing address

PO BOX 519
MONTICELLO UT
84535-0519
US

V. Phone/Fax

Practice location:
  • Phone: 435-587-2302
  • Fax: 435-587-3441
Mailing address:
  • Phone: 435-587-2302
  • Fax: 435-587-3441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: TYLER GILSON
Title or Position: PRESIDENT/PHARMACIST
Credential: PHARMD
Phone: 435-650-2736