Provider Demographics
NPI:1912403502
Name:MARCHANTS PHARM WAGON
Entity type:Organization
Organization Name:MARCHANTS PHARM WAGON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:MARCHANT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:435-691-4288
Mailing Address - Street 1:390 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SANTAQUIN
Mailing Address - State:UT
Mailing Address - Zip Code:84655-7078
Mailing Address - Country:US
Mailing Address - Phone:801-754-1141
Mailing Address - Fax:801-754-3141
Practice Address - Street 1:390 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SANTAQUIN
Practice Address - State:UT
Practice Address - Zip Code:84655-7078
Practice Address - Country:US
Practice Address - Phone:801-754-1141
Practice Address - Fax:801-754-3141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-02
Last Update Date:2022-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT107010413336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1912403502Medicaid