Provider Demographics
NPI:1972657179
Name:TETON COUNTY HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:TETON COUNTY HOSPITAL DISTRICT
Other - Org Name:ST JOHN'S MEDICAL CENTER 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:JEAN
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:307-739-6172
Mailing Address - Fax:307-739-7698
Practice Address - Street 1:625 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8642
Practice Address - Country:US
Practice Address - Phone:307-739-6172
Practice Address - Fax:307-739-7698
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TETON COUNTY HOSPITAL DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-23
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY52011023336I0012X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY106299907Medicaid