Provider Demographics
NPI:1942527080
Name:DLN PC
Entity Type:Organization
Organization Name:DLN PC
Other - Org Name:TOWN AND COUNTRY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:NOVICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-634-6662
Mailing Address - Street 1:514 S GREELEY HWY
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82007-2852
Mailing Address - Country:US
Mailing Address - Phone:307-634-6662
Mailing Address - Fax:307-634-6670
Practice Address - Street 1:514 S GREELEY HWY
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82007-2852
Practice Address - Country:US
Practice Address - Phone:307-634-6662
Practice Address - Fax:307-634-6670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-29
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WYR100603336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5204297OtherNCPDP PROVIDER IDENTIFICATION NUMBER
WY1942527080Medicaid
5204297OtherNCPDP PROVIDER IDENTIFICATION NUMBER