Healthcare Provider Details

I. General information

NPI: 1427381714
Provider Name (Legal Business Name): ASSOCIATED FRESH MARKETS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2009
Last Update Date: 04/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 W CENTER ST
PROVO UT
84601-4276
US

IV. Provider business mailing address

PO BOX 26908
SALT LAKE CITY UT
84126-0908
US

V. Phone/Fax

Practice location:
  • Phone: 801-374-1704
  • Fax: 801-374-0964
Mailing address:
  • Phone: 801-978-8225
  • Fax: 801-978-8634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number7442351-1703
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SHAWNA HANSON
Title or Position: DIRECTOR, PHARMACY OPERATIONS
Credential: PHARMD
Phone: 801-978-8309