Provider Demographics
NPI:1649382565
Name:VICKLUND INC.
Entity Type:Organization
Organization Name:VICKLUND INC.
Other - Org Name:VICKLUND PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MR.
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEROMEDI
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:307-864-2369
Mailing Address - Street 1:610 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:THERMOPOLIS
Mailing Address - State:WY
Mailing Address - Zip Code:82443-3202
Mailing Address - Country:US
Mailing Address - Phone:307-864-2369
Mailing Address - Fax:307-864-9202
Practice Address - Street 1:610 S 6TH ST
Practice Address - Street 2:
Practice Address - City:THERMOPOLIS
Practice Address - State:WY
Practice Address - Zip Code:82443-3202
Practice Address - Country:US
Practice Address - Phone:307-864-2369
Practice Address - Fax:307-864-9202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYR10114333600000X, 3336C0003X
WY52-022433336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2146836OtherPK
5202243OtherNCPDP PROVIDER IDENTIFICATION NUMBER
5202243OtherNCPDP