Basic Information
| Provider Information | |||||||||
| NPI: | 1689021933 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CANYONLANDS COMMUNITY HEALTH CARE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CANYONLANDS COMMUNITY HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1625 | ||||||||
| Address2: | |||||||||
| City: | PAGE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860401625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286456620 | ||||||||
| FaxNumber: | 9286456621 | ||||||||
| Practice Location | |||||||||
| Address1: | 467 VISTA AVENUE | ||||||||
| Address2: | |||||||||
| City: | PAGE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286456620 | ||||||||
| FaxNumber: | 9286456621 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2016 | ||||||||
| LastUpdateDate: | 09/23/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEWANDOWSKI | ||||||||
| AuthorizedOfficialFirstName: | ANDREW | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PHARMACY, PIC, AO | ||||||||
| AuthorizedOfficialTelephone: | 9286456620 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHARMD | ||||||||
| NPICertificationDate: | 09/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | Y006821 | AZ | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2160535 | 01 | PK | OTHER | 174027 | 05 | AZ | MEDICAID | 1689021933 | 05 | UT | MEDICAID |