Healthcare Provider Details

I. General information

NPI: 1174559330
Provider Name (Legal Business Name): PAYSON FOOD CORPORATION INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 01/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

586 N MAIN ST
PAYSON UT
84651-3428
US

IV. Provider business mailing address

586 N MAIN ST
PAYSON UT
84651-3428
US

V. Phone/Fax

Practice location:
  • Phone: 801-465-2343
  • Fax: 801-465-0856
Mailing address:
  • Phone: 801-465-2343
  • Fax: 801-465-0856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number332540-1703
License Number StateUT

VII. Legacy identifiers

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

# 1
Identifier4608521
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerNCPDP

VIII. Authorized Official

Name: MR. HAROLD MEASOM
Title or Position: PHARMACY MANAGER
Credential: PHARM.D
Phone: 801-465-2343