Healthcare Provider Details

I. General information

NPI: 1215144308
Provider Name (Legal Business Name): SAN JUAN PHARMACY MONTICELLO INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 04/13/2022
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 S MAIN ST
MONTICELLO UT
84535
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 Number127088-1703
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: TIM YOUNG
Title or Position: OWNER
Credential:
Phone: 435-587-2302