Provider Demographics
NPI:1346282951
Name:CANYON PHARMACEUTICAL, LLC
Entity Type:Organization
Organization Name:CANYON PHARMACEUTICAL, LLC
Other - Org Name:ROCK CANYON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-440-2995
Mailing Address - Street 1:3179 N CANYON RD
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3916
Mailing Address - Country:US
Mailing Address - Phone:801-377-2002
Mailing Address - Fax:801-377-2007
Practice Address - Street 1:3179 N CANYON RD
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3916
Practice Address - Country:US
Practice Address - Phone:801-377-2002
Practice Address - Fax:801-377-2007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT50843661703183500000X
3336C0003X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT710871500008Medicaid
UT=========008Medicaid