Healthcare Provider Details

I. General information

NPI: 1912403502
Provider Name (Legal Business Name): MARCHANTS PHARM WAGON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 02/19/2022
Certification Date: 02/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 E MAIN ST
SANTAQUIN UT
84655-7078
US

IV. Provider business mailing address

390 E MAIN ST
SANTAQUIN UT
84655-7078
US

V. Phone/Fax

Practice location:
  • Phone: 801-754-1141
  • Fax: 801-754-3141
Mailing address:
  • Phone: 801-754-1141
  • Fax: 801-754-3141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number10701041
License Number StateUT

VIII. Authorized Official

Name: DR. KEVIN SCOTT MARCHANT
Title or Position: OWNER/MANAGER
Credential: PHARM.D.
Phone: 435-691-4288