Provider Demographics
NPI:1639482532
Name:SOUTH STREET PHARMACY, LLC
Entity Type:Organization
Organization Name:SOUTH STREET PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CORINDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:GEILE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:307-322-2486
Mailing Address - Street 1:1456 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:WHEATLAND
Mailing Address - State:WY
Mailing Address - Zip Code:82201-2736
Mailing Address - Country:US
Mailing Address - Phone:307-322-2486
Mailing Address - Fax:
Practice Address - Street 1:1456 SOUTH ST
Practice Address - Street 2:
Practice Address - City:WHEATLAND
Practice Address - State:WY
Practice Address - Zip Code:82201-2736
Practice Address - Country:US
Practice Address - Phone:307-322-2486
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-20
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
WYR10063333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY129737600Medicaid
WY129737600Medicaid