Provider Demographics
NPI:1891770715
Name:PROFESSIONAL PARK PHARMACY INC
Entity Type:Organization
Organization Name:PROFESSIONAL PARK PHARMACY INC
Other - Org Name:PROFESSIONAL PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:R BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-652-1548
Mailing Address - Street 1:736 S 900 E STE 102
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-7001
Mailing Address - Country:US
Mailing Address - Phone:435-652-1548
Mailing Address - Fax:435-652-3059
Practice Address - Street 1:736 S 900 E STE 102
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-7001
Practice Address - Country:US
Practice Address - Phone:435-652-1548
Practice Address - Fax:435-652-3059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-13
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
UT35067717033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2100294OtherPK
UT=========000Medicaid