MEDICARE: LSJ FAMILY DRUG DBA LSJ UNITED DRUG

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	183500000X	Pharmacist	1319181701	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4610196	OTHER	UT	NCPDP

General Provider Information

NPI Number	:	1447323357
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LSJ FAMILY DRUG DBA LSJ UNITED DRUG

Provider Business Mailing Address
First Line	:	PO BOX 841429
Second Line	:	1280 WEST UTAH AVENUE
City	:	HILDALE
State	:	UT
Zip	:	84784-1429
Country	:	US
Telephone Number	:	435-874-1415
Fax Number	:	435-874-1417

Provider Business Practice Location Address
First Line	:	1280 WEST UTAH AVENUE
Second Line	:
City	:	HILDALE
State	:	UT
Zip	:	84784-1429
Country	:	US
Telephone Number	:	435-874-1415
Fax Number	:	435-874-1417

Authorized Official
Title or Position	:	OWNER
Name	:	MR. JOSEPH G JOHNSON
Credential	:	RPH
Telephone Number	:	435-874-1415

Provider Enumeration Date	:	11/16/2006
Last Update Date	:	06/20/2008

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