MEDICARE: HEALTHWISE 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	8359105-1704	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2100773	OTHER		PK

General Provider Information

NPI Number	:	1790902898
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALTHWISE 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	:	801-489-7300
Fax Number	:	801-489-4949

Provider Business Practice Location Address
First Line	:	724 S 1600 W
Second Line	:
City	:	MAPLETON
State	:	UT
Zip	:	84664-4347
Country	:	US
Telephone Number	:	801-489-7300
Fax Number	:	801-489-4949

Authorized Official
Title or Position	:	PHARMACIST IN CHARGE
Name	:	RYAN HICKMAN
Credential	:
Telephone Number	:	801-489-7300

Provider Enumeration Date	:	04/19/2007
Last Update Date	:	10/05/2015

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Directions to “HEALTHWISE PHARMACY INC ” Practice Location

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