Healthcare Provider Details

I. General information

NPI: 1891770715
Provider Name (Legal Business Name): PROFESSIONAL PARK PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 11/15/2022
Certification Date: 11/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

736 S 900 E STE 102
ST GEORGE UT
84790-7001
US

IV. Provider business mailing address

736 S 900 E STE 102
ST GEORGE UT
84790-7001
US

V. Phone/Fax

Practice location:
  • Phone: 435-652-1548
  • Fax: 435-652-3059
Mailing address:
  • Phone: 435-652-1548
  • Fax: 435-652-3059

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 Number3506771703
License Number StateUT

VIII. Authorized Official

Name: R BRAD ANDERSON
Title or Position: PRESIDENT
Credential:
Phone: 435-652-1548