Provider Demographics
NPI:1235402132
Name:AFTON FAMILY PHARMACY
Entity Type:Organization
Organization Name:AFTON FAMILY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:BRET
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:435-512-8202
Mailing Address - Street 1:141 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:AFTON
Mailing Address - State:WY
Mailing Address - Zip Code:83110
Mailing Address - Country:US
Mailing Address - Phone:435-512-8202
Mailing Address - Fax:
Practice Address - Street 1:141 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:AFTON
Practice Address - State:WY
Practice Address - Zip Code:83110
Practice Address - Country:US
Practice Address - Phone:435-512-8202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-23
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy