Provider Demographics
NPI:1518050947
Name:WESTON COUNTY HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:WESTON COUNTY HOSPITAL DISTRICT
Other - Org Name:WESTON COUNTY HEALTH SERVICES PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:TAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:WEIDENBACH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:307-746-3742
Mailing Address - Street 1:1124 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:WY
Mailing Address - Zip Code:82701-2972
Mailing Address - Country:US
Mailing Address - Phone:307-746-3742
Mailing Address - Fax:307-746-3724
Practice Address - Street 1:1124 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:NEWCASTLE
Practice Address - State:WY
Practice Address - Zip Code:82701-2972
Practice Address - Country:US
Practice Address - Phone:307-746-3742
Practice Address - Fax:307-746-3724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336I0012X
WY52026093336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2111452OtherPK
WY114292500Medicaid