Provider Demographics
NPI:1164556833
Name:WYMED SUPPLY, LLC.
Entity type:Organization
Organization Name:WYMED SUPPLY, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:B
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-234-3047
Mailing Address - Street 1:1347 S WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-2936
Mailing Address - Country:US
Mailing Address - Phone:307-234-3047
Mailing Address - Fax:307-234-3897
Practice Address - Street 1:1347 S WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-2936
Practice Address - Country:US
Practice Address - Phone:307-234-3047
Practice Address - Fax:307-234-3897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY119089001Medicaid
WY4991260001Medicare NSC