MEDICARE: MARKET PHARMACY

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	64324271703	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4610766	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1366573461
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARKET PHARMACY

Provider Business Mailing Address
First Line	:	495 N STATE ST
Second Line	:
City	:	LA VERKIN
State	:	UT
Zip	:	84745-5124
Country	:	US
Telephone Number	:	435-635-8880
Fax Number	:	435-635-1537

Provider Business Practice Location Address
First Line	:	495 N STATE ST
Second Line	:
City	:	LA VERKIN
State	:	UT
Zip	:	84745-5124
Country	:	US
Telephone Number	:	435-635-8880
Fax Number	:	435-635-1537

Authorized Official
Title or Position	:	MANAGER / OWNER
Name	:	CLIFFORD HOLT
Credential	:	RPH
Telephone Number	:	435-635-8880

Provider Enumeration Date	:	03/08/2007
Last Update Date	:	05/17/2010

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Directions to “MARKET PHARMACY ” Practice Location

Language	Start Address	Practice Location

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