Provider Demographics
NPI:1316958804
Name:PROFESSIONAL PLAZA PHARMACY INC
Entity type:Organization
Organization Name:PROFESSIONAL PLAZA PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMBLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-773-3863
Mailing Address - Street 1:2065 N ROBBINS DR
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-1133
Mailing Address - Country:US
Mailing Address - Phone:801-773-3863
Mailing Address - Fax:801-773-3892
Practice Address - Street 1:2065 N ROBBINS DR
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-1133
Practice Address - Country:US
Practice Address - Phone:801-773-3863
Practice Address - Fax:801-773-3892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
UT13355417033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2107760OtherPK
2107760OtherPK
UT=========005Medicaid