Provider Demographics
NPI:1003995788
Name:BUFFALO PRESCRIPTION SHOP, INC
Entity Type:Organization
Organization Name:BUFFALO PRESCRIPTION SHOP, INC
Other - Org Name:BUFFALO PRESCRIPTION SHOP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/PHARMACIST-IN-CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:TOM
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:MAERTENS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:307-684-7003
Mailing Address - Street 1:431 FORT ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:WY
Mailing Address - Zip Code:82834-1805
Mailing Address - Country:US
Mailing Address - Phone:307-684-7003
Mailing Address - Fax:307-684-7348
Practice Address - Street 1:431 FORT ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:WY
Practice Address - Zip Code:82834-1805
Practice Address - Country:US
Practice Address - Phone:307-684-7003
Practice Address - Fax:307-684-7348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
WY52001123336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2111130OtherPK
WY106888100Medicaid
2111130OtherPK