Provider Demographics
NPI:1245521954
Name:PARK CITY CLINIC PHARMACY
Entity type:Organization
Organization Name:PARK CITY CLINIC PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KORTNEY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:STIRLAND
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:435-644-2702
Mailing Address - Street 1:14 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:KANAB
Mailing Address - State:UT
Mailing Address - Zip Code:84741-3542
Mailing Address - Country:US
Mailing Address - Phone:435-644-2693
Mailing Address - Fax:
Practice Address - Street 1:750 ROUND VALLEY DR
Practice Address - Street 2:203
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098
Practice Address - Country:US
Practice Address - Phone:435-644-2702
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-28
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7955094-1703333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy