Provider Demographics
NPI:1033630918
Name:BLUE SPARROW WELLNESS PHARMACY
Entity Type:Organization
Organization Name:BLUE SPARROW WELLNESS PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST IN CHARGE
Authorized Official - Prefix:DR
Authorized Official - First Name:CODY
Authorized Official - Middle Name:KIM
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:435-674-0201
Mailing Address - Street 1:558 E RIVERSIDE DR STE 104
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-7176
Mailing Address - Country:US
Mailing Address - Phone:435-674-0201
Mailing Address - Fax:435-674-0217
Practice Address - Street 1:558 E RIVERSIDE DR STE 104
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-7176
Practice Address - Country:US
Practice Address - Phone:435-674-0201
Practice Address - Fax:435-674-0217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5725931-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty