MEDICARE: SUNDANCE PHARMACY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336M0002X	Mail Order Pharmacy	56416441704	UT

General Provider Information

NPI Number	:	1033264130
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNDANCE PHARMACY LLC

Provider Business Mailing Address
First Line	:	538 N 1300 E
Second Line	:
City	:	SAINT GEORGE
State	:	UT
Zip	:	84770-3222
Country	:	US
Telephone Number	:	435-673-9204
Fax Number	:	435-628-2865

Provider Business Practice Location Address
First Line	:	538 N 1300 E
Second Line	:
City	:	SAINT GEORGE
State	:	UT
Zip	:	84770-3222
Country	:	US
Telephone Number	:	435-673-9204
Fax Number	:	435-628-2865

Authorized Official
Title or Position	:	PHARMACIST MANAGER
Name	:	MR. CLEM MCEWEN
Credential	:
Telephone Number	:	435-673-9204

Provider Enumeration Date	:	01/25/2007
Last Update Date	:	08/22/2020

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