Provider Demographics
NPI:1346343498
Name:STAR VALLEY DRUG CO
Entity Type:Organization
Organization Name:STAR VALLEY DRUG CO
Other - Org Name:LOWER VALLEY DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:STAUFFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-885-9804
Mailing Address - Street 1:PO BOX 1006
Mailing Address - Street 2:190 N MAIN
Mailing Address - City:THAYNE
Mailing Address - State:WY
Mailing Address - Zip Code:83127-1006
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:190 N MAIN
Practice Address - Street 2:
Practice Address - City:THAYNE
Practice Address - State:WY
Practice Address - Zip Code:83127-1006
Practice Address - Country:US
Practice Address - Phone:307-883-4600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
WY5203031333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY110016500Medicaid
5203031OtherOTHER ID NUMBER-COMMERCIAL NUMBER
WY0028895Medicaid
WY110016500Medicaid