Provider Demographics
NPI:1073673042
Name:COMMUNITY HEALTH CENTER OF CENTRAL WYOMING INC
Entity Type:Organization
Organization Name:COMMUNITY HEALTH CENTER OF CENTRAL WYOMING INC
Other - Org Name:COMMUNITY HEALTH CENTER OF CENTRAL WYOMING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:DORNBIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-233-6050
Mailing Address - Street 1:5000 BLACKMORE RD
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-3345
Mailing Address - Country:US
Mailing Address - Phone:307-233-6050
Mailing Address - Fax:307-233-6087
Practice Address - Street 1:5000 BLACKMORE RD
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-3345
Practice Address - Country:US
Practice Address - Phone:307-233-6050
Practice Address - Fax:307-233-6087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2022-03-28
Deactivation Date:2016-10-25
Deactivation Code:
Reactivation Date:2016-11-15
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
WY52016213336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY115261101Medicaid
2111284OtherPK
5201621OtherNCPDP PROVIDER IDENTIFICATION NUMBER