MEDICARE: SKYLINE PHARMACY 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	332B00000X	Durable Medical Equipment & Medical Supplies
2	332BP3500X	Parenteral & Enteral Nutrition Supplies (DME)	131751-1703	UT
3	3336C0004X	Compounding Pharmacy	131751-1703	UT
4	3336H0001X	Home Infusion Therapy Pharmacy	131751-1703	UT
5	3336C0003X	Community/Retail Pharmacy	131751-1703	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4606301	OTHER	UT	NABP#
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356426753
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SKYLINE PHARMACY INC.

Provider Business Mailing Address
First Line	:	1 W MAIN ST
Second Line	:
City	:	MT PLEASANT
State	:	UT
Zip	:	84647-1327
Country	:	US
Telephone Number	:	435-462-2434
Fax Number	:	435-462-3400

Provider Business Practice Location Address
First Line	:	1 W MAIN ST
Second Line	:
City	:	MT PLEASANT
State	:	UT
Zip	:	84647-1327
Country	:	US
Telephone Number	:	435-462-2434
Fax Number	:	435-462-3400

Authorized Official
Title or Position	:	PHARMACY DIRECTOR
Name	:	MR. DAVID HOWARD BLACKHAM
Credential	:	RPH
Telephone Number	:	435-462-2434

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	11/12/2007

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Directions to “SKYLINE PHARMACY INC. ” Practice Location

Language	Start Address	Practice Location

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