Provider Demographics
NPI:1659429660
Name:PROFESSIONAL PHARMACY INC
Entity Type:Organization
Organization Name:PROFESSIONAL PHARMACY INC
Other - Org Name:BI RITE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFC MNGR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:ENGSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-324-3403
Mailing Address - Street 1:PO BOX 699
Mailing Address - Street 2:
Mailing Address - City:RAWLINS
Mailing Address - State:WY
Mailing Address - Zip Code:82301-0699
Mailing Address - Country:US
Mailing Address - Phone:307-324-3403
Mailing Address - Fax:307-324-5099
Practice Address - Street 1:300 3RD ST
Practice Address - Street 2:
Practice Address - City:RAWLINS
Practice Address - State:WY
Practice Address - Zip Code:82301-5612
Practice Address - Country:US
Practice Address - Phone:307-324-3403
Practice Address - Fax:307-324-5099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WY52027863336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY104131200Medicaid
2111469OtherPK
0679840001Medicare NSC