Provider Demographics
NPI:1417123167
Name:CHEYENNE HEALTH & WELLNESS CENTER
Entity Type:Organization
Organization Name:CHEYENNE HEALTH & WELLNESS CENTER
Other - Org Name:HEALTHWORKS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:SQUIRES
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:307-635-3618
Mailing Address - Street 1:2508 E FOX FARM RD
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82007-2559
Mailing Address - Country:US
Mailing Address - Phone:307-637-7000
Mailing Address - Fax:307-637-7002
Practice Address - Street 1:2508 E FOX FARM RD STE 1B
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:307-637-7000
Practice Address - Fax:307-637-7002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-02
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WYR100693336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY121709701Medicaid
2111705OtherPK