Healthcare Provider Details

I. General information

NPI: 1386244861
Provider Name (Legal Business Name): CANYONLANDS COMMUNITY HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2020
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 MAIN ST
DUNCAN AZ
85534-9701
US

IV. Provider business mailing address

PO BOX 708
DUNCAN AZ
85534-0708
US

V. Phone/Fax

Practice location:
  • Phone: 928-645-9675
  • Fax:
Mailing address:
  • Phone: 928-645-6620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JODI TATE
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 928-645-9675