Provider Demographics
NPI:1003099342
Name:OSBORN, THEODORE (PHARMD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:OSBORN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:TED
Other - Middle Name:
Other - Last Name:OSBORN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHARMD
Mailing Address - Street 1:1898 FORT RD
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-8320
Mailing Address - Country:US
Mailing Address - Phone:307-675-3102
Mailing Address - Fax:
Practice Address - Street 1:1898 FORT RD
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-8320
Practice Address - Country:US
Practice Address - Phone:307-675-3102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-10
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
SD6313183500000X, 1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No183500000XPharmacy Service ProvidersPharmacist