Provider Demographics
NPI:1780288571
Name:PROFESSIONAL PARK PHARMACY INC
Entity type:Organization
Organization Name:PROFESSIONAL PARK PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:BRAD
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:435-652-1548
Mailing Address - Street 1:2825 E MALL DR
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-1954
Mailing Address - Country:US
Mailing Address - Phone:435-429-6700
Mailing Address - Fax:
Practice Address - Street 1:2825 EAST MALL DRIVE
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-8479
Practice Address - Country:US
Practice Address - Phone:435-429-6700
Practice Address - Fax:435-652-3059
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROFESSIONAL PARK PHARMACY TWO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-11-23
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy