Basic Information
| Provider Information | |||||||||
| NPI: | 1801526603 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CANYONLANDS COMMUNITY HEALTH CARE | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1625 | ||||||||
| Address2: | |||||||||
| City: | PAGE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860401625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286459675 | ||||||||
| FaxNumber: | 9286452626 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 N SANDHILL BLVD | ||||||||
| Address2: | |||||||||
| City: | MESQUITE | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890274789 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028490558 | ||||||||
| FaxNumber: | 7023462147 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2022 | ||||||||
| LastUpdateDate: | 06/14/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | REED | ||||||||
| AuthorizedOfficialFirstName: | MARI | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 9286459675 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CANYONLANDS COMMUNITY HEALTH CARE | ||||||||
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| NPICertificationDate: | 06/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | PH04420 | 01 | NV | STATE LICENSE | OTHER |