Healthcare Provider Details

I. General information

NPI: 1871812370
Provider Name (Legal Business Name): MOUNTAINLANDS FAMILY PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2010
Last Update Date: 03/27/2025
Certification Date: 03/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

589 S STATE ST
PROVO UT
84606-5056
US

IV. Provider business mailing address

589 S STATE ST
PROVO UT
84606-5056
US

V. Phone/Fax

Practice location:
  • Phone: 801-429-2000
  • Fax:
Mailing address:
  • Phone: 801-429-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number7630544-1703
License Number StateUT

VIII. Authorized Official

Name: TODD BAILEY
Title or Position: CEO
Credential:
Phone: 801-429-2011