Healthcare Provider Details

I. General information

NPI: 1205929650
Provider Name (Legal Business Name): SAN JUAN PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2006
Last Update Date: 11/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 S MAIN ST
BLANDING UT
84511-3742
US

IV. Provider business mailing address

65 S MAIN ST
BLANDING UT
84511-3742
US

V. Phone/Fax

Practice location:
  • Phone: 435-678-2781
  • Fax: 435-678-2379
Mailing address:
  • Phone: 435-678-2781
  • Fax: 435-678-2379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number1271021703
License Number StateUT

VIII. Authorized Official

Name: DANA NIELSON
Title or Position: PHARMACIST
Credential:
Phone: 435-678-2781