Healthcare Provider Details

I. General information

NPI: 1033860028
Provider Name (Legal Business Name): SHANE GURLEY PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2022
Last Update Date: 01/12/2022
Certification Date: 01/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 S 200 W
BLANDING UT
84511-3910
US

IV. Provider business mailing address

1128 N RESERVOIR RD
BLANDING UT
84511-3426
US

V. Phone/Fax

Practice location:
  • Phone: 435-678-4640
  • Fax:
Mailing address:
  • Phone: 801-691-3147
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number11179034-1701
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: