Provider Demographics
NPI:1376524280
Name:PANGUITCH DRUG CORP
Entity Type:Organization
Organization Name:PANGUITCH DRUG CORP
Other - Org Name:PANGUITCH DRUG CO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:435-676-2212
Mailing Address - Street 1:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:PANGUITCH
Mailing Address - State:UT
Mailing Address - Zip Code:84759-0068
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:95 E CENTER
Practice Address - Street 2:
Practice Address - City:PANGUITCH
Practice Address - State:UT
Practice Address - Zip Code:84759-0068
Practice Address - Country:US
Practice Address - Phone:435-676-2212
Practice Address - Fax:435-676-8850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-08
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
UT34179517033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870287657001Medicaid
4601894OtherNCPDP PROVIDER IDENTIFICATION NUMBER
0872900001Medicare NSC