# SAN JUAN PHARMACY MONTICELLO INC.

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- **Entity:** Organization
- **Status:** Active
- **Other names:** MAIN STREET DRUG & BOUTIQUE
- **Organization subpart:** No

## Provider details

- **NPI number:** 1215144308
- **Authorized official:** TIM YOUNG (OWNER)
- **Authorized official phone:** (435) 587-2302

## Contact information

- **Practice address:** 140 S MAIN ST, MONTICELLO, UT 84535
- **Practice address phone:** (435) 587-2302
- **Practice address fax:** (435) 587-3441
- **Mailing address:** PO BOX 519, MONTICELLO, UT 84535-0519
- **Mailing address phone:** (435) 587-2302
- **Mailing address fax:** (435) 587-3441

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 3336C0003X | Community/Retail Pharmacy | 127088-1703 | UT | Yes |
| 3336C0004X | Compounding Pharmacy | — | NULL | — |

## Other

- **Enumeration date:** 05/17/2007
- **Last updated:** 04/13/2022

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 2107592 | PK | — |
| 05 | — | 876000616040 | — | UT |
| 05 | — | 88084876 | — | CO |