Provider Demographics
NPI:1952823783
Name:TETON COUNTY HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:TETON COUNTY HOSPITAL DISTRICT
Other - Org Name:ST. JOHN'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:ALISA
Authorized Official - Middle Name:
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-739-7641
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-0428
Mailing Address - Country:US
Mailing Address - Phone:307-739-7656
Mailing Address - Fax:307-739-7658
Practice Address - Street 1:555 E BROADWAY AVE STE 212
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8640
Practice Address - Country:US
Practice Address - Phone:307-739-7656
Practice Address - Fax:307-739-7658
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TETON COUNTY HOSPITAL DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-07-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYR101673336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYR10167OtherSTATE LICENSE NUMBER