Provider Demographics
NPI:1033264130
Name:SUNDANCE PHARMACY LLC
Entity Type:Organization
Organization Name:SUNDANCE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CLEM
Authorized Official - Middle Name:
Authorized Official - Last Name:MCEWEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-673-9204
Mailing Address - Street 1:538 N 1300 E
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-3222
Mailing Address - Country:US
Mailing Address - Phone:435-673-9204
Mailing Address - Fax:435-628-2865
Practice Address - Street 1:538 N 1300 E
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-3222
Practice Address - Country:US
Practice Address - Phone:435-673-9204
Practice Address - Fax:435-628-2865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT564164417043336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT4610300Medicare ID - Type Unspecified