MEDICARE: MAPLE MOUNTAIN 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	3336L0003X	Long Term Care Pharmacy
2	333600000X	Pharmacy	8359109-1703	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2167468	OTHER		PK

General Provider Information

NPI Number	:	1487192621
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAPLE MOUNTAIN PHARMACY INC.

Provider Business Mailing Address
First Line	:	724 S 1600 W
Second Line	:
City	:	MAPLETON
State	:	UT
Zip	:	84664-4347
Country	:	US
Telephone Number	:	801-515-6048
Fax Number	:

Provider Business Practice Location Address
First Line	:	724 S 1600 W
Second Line	:
City	:	MAPLETON
State	:	UT
Zip	:	84664-4347
Country	:	US
Telephone Number	:	801-515-6048
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	MICHAEL JOHNSON
Credential	:
Telephone Number	:	801-885-1147

Provider Enumeration Date	:	02/08/2017
Last Update Date	:	02/08/2017

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