=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124132113
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PC PHARMACY AT THE CLINIC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2006
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1665 BONANZA DR
-----------------------------------------------------
City | PARK CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84060
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-658-5051
-----------------------------------------------------
Fax | 435-658-5093
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 680772
-----------------------------------------------------
City | PARK CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84068-0772
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KRISTY BLACK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 435-658-5051
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 60427351703
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------