Healthcare Provider Details

I. General information

NPI: 1245521954
Provider Name (Legal Business Name): PARK CITY CLINIC PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2011
Last Update Date: 04/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 ROUND VALLEY DR 203
PARK CITY UT
84098
US

IV. Provider business mailing address

14 E CENTER ST
KANAB UT
84741-3542
US

V. Phone/Fax

Practice location:
  • Phone: 435-644-2702
  • Fax:
Mailing address:
  • Phone: 435-644-2693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number7955094-1703
License Number StateUT

VIII. Authorized Official

Name: KORTNEY JAMES STIRLAND
Title or Position: OWNER
Credential: RPH
Phone: 435-644-2702