Provider Demographics
NPI:1154661320
Name:WYOMING MEDICATION DONATION PROGRAM
Entity Type:Organization
Organization Name:WYOMING MEDICATION DONATION PROGRAM
Other - Org Name:WYOMING MEDICATION DONATION PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARM.D., PIC, PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NATASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLIZZI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-635-1297
Mailing Address - Street 1:2300 CAPITOL AVE STE B-27
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-3672
Mailing Address - Country:US
Mailing Address - Phone:307-635-1297
Mailing Address - Fax:307-635-2156
Practice Address - Street 1:2508 E FOX FARM RD STE 2A
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82007-2559
Practice Address - Country:US
Practice Address - Phone:307-635-1297
Practice Address - Fax:307-635-2156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-25
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336M0002X
WYR100653336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5204487OtherNCPDP PROVIDER IDENTIFICATION NUMBER