Provider Demographics
NPI:1386106896
Name:GUNNISON FAMILY PHARMACY & FLORAL INC
Entity type:Organization
Organization Name:GUNNISON FAMILY PHARMACY & FLORAL INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:ADAM
Authorized Official - Last Name:HARDY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:435-528-3455
Mailing Address - Street 1:PO BOX 789
Mailing Address - Street 2:
Mailing Address - City:GUNNISON
Mailing Address - State:UT
Mailing Address - Zip Code:84634-0789
Mailing Address - Country:US
Mailing Address - Phone:435-528-3455
Mailing Address - Fax:435-528-3776
Practice Address - Street 1:77 S MAIN ST
Practice Address - Street 2:
Practice Address - City:GUNNISON
Practice Address - State:UT
Practice Address - Zip Code:84634-7706
Practice Address - Country:US
Practice Address - Phone:435-528-3455
Practice Address - Fax:435-528-3776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-03
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT646037165001Medicaid