Provider Demographics
NPI:1689021933
Name:CANYONLANDS COMMUNITY HEALTH CARE
Entity type:Organization
Organization Name:CANYONLANDS COMMUNITY HEALTH CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY, PIC, AO
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWANDOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:928-645-6620
Mailing Address - Street 1:PO BOX 1625
Mailing Address - Street 2:
Mailing Address - City:PAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:86040-1625
Mailing Address - Country:US
Mailing Address - Phone:928-645-6620
Mailing Address - Fax:928-645-6621
Practice Address - Street 1:467 VISTA AVENUE
Practice Address - Street 2:
Practice Address - City:PAGE
Practice Address - State:AZ
Practice Address - Zip Code:86040
Practice Address - Country:US
Practice Address - Phone:928-645-6620
Practice Address - Fax:928-645-6621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-17
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AZY0068213336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2160535OtherPK
AZ174027Medicaid
UT1689021933Medicaid