Healthcare Provider Details

I. General information

NPI: 1295483782
Provider Name (Legal Business Name): LION PRIDE PHARMACY AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2022
Last Update Date: 03/14/2022
Certification Date: 03/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

163 W 1600 S STE 3
SAINT GEORGE UT
84770-6715
US

IV. Provider business mailing address

163 W 1600 S STE 3
SAINT GEORGE UT
84770-6715
US

V. Phone/Fax

Practice location:
  • Phone: 435-628-2066
  • Fax: 435-623-2887
Mailing address:
  • Phone: 435-628-2066
  • Fax: 435-623-2887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code335G00000X
TaxonomyMedical Foods Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. MICAH KEALOHA HARWARD
Title or Position: MEMBER/ PHARMAIST IN CHARGE
Credential: PHARMD
Phone: 435-628-2066