MEDICARE: WINEGARS SUPER MARKETS INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	9423319-1703	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2154481	OTHER		PK

General Provider Information

NPI Number	:	1205819968
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WINEGARS SUPER MARKETS INC

Provider Business Mailing Address
First Line	:	574 W 3400 S
Second Line	:
City	:	BOUNTIFUL
State	:	UT
Zip	:	84010-8036
Country	:	US
Telephone Number	:	801-298-5407
Fax Number	:	801-298-5463

Provider Business Practice Location Address
First Line	:	1080 W 300 N
Second Line	:
City	:	CLEARFIELD
State	:	UT
Zip	:	84015-8732
Country	:	US
Telephone Number	:	801-773-7330
Fax Number	:	801-525-0175

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	LONNY WINEGAR
Credential	:
Telephone Number	:	801-298-5407

Provider Enumeration Date	:	11/26/2005
Last Update Date	:	10/07/2015

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Directions to “WINEGARS SUPER MARKETS INC ” Practice Location

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