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General NPI Number Information
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NPI Number | 1033630918
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Entity Type | Organization
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Legal Business Name | BLUE SPARROW WELLNESS PHARMACY
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Dates
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Enumeration Date | 06/30/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 558 E RIVERSIDE DR STE 104
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City | ST GEORGE
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State | UT
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Zip | 84790-7176
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Country | US
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Telephone | 435-674-0201
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Fax | 435-674-0217
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Provider Business Mailing Address
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Address Line | 558 E RIVERSIDE DR STE 104
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City | ST GEORGE
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State | UT
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Zip | 84790-7176
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Country | US
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Telephone | 435-674-0201
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Fax | 435-674-0217
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Authorized Official
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Title or Position | OWNER/PHARMACIST IN CHARGE
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Name | DR. CODY KIM HANSEN
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Credential | PHARMACIST
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Telephone | 435-674-0201
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 5725931-1701
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License Number State | UT
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