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General NPI Number Information
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NPI Number | 1164795431
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Entity Type | Organization
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Legal Business Name | MIDWAY PHARMACY
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Dates
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Enumeration Date | 02/17/2012
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Last Update Date | 03/25/2013
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Provider Practice Location Address
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Address Line | 42 W MAIN ST
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City | MIDWAY
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State | UT
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Zip | 84049-6313
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Country | US
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Telephone | 435-654-1926
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Fax | 435-654-3039
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Provider Business Mailing Address
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Address Line | PO BOX 26417
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City | SALT LAKE CITY
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State | UT
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Zip | 84126-0417
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Country | US
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Telephone | 435-654-1926
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Fax | 435-654-3039
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Authorized Official
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Title or Position | PHARMACY MANAGER/PIC
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Name | DANIEL COOK
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Credential | PHARMD
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Telephone | 435-657-0170
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 8208474-1703
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License Number State | UT
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