Provider Demographics
NPI:1104394907
Name:UNIVERSITY OF WYOMING
Entity Type:Organization
Organization Name:UNIVERSITY OF WYOMING
Other - Org Name:WYOMING FAMILY PRACTICE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LYLE
Authorized Official - Middle Name:D
Authorized Official - Last Name:SVOBODA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-232-6079
Mailing Address - Street 1:1522 E A ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2217
Mailing Address - Country:US
Mailing Address - Phone:307-232-6079
Mailing Address - Fax:
Practice Address - Street 1:1522 E A ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2217
Practice Address - Country:US
Practice Address - Phone:307-265-4446
Practice Address - Fax:307-472-2881
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF WYOMING
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-11-09
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy