Provider Demographics
NPI:1649660671
Name:WESTON COUNTY HOSPITAL DISTRICT
Entity type:Organization
Organization Name:WESTON COUNTY HOSPITAL DISTRICT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY/AO
Authorized Official - Prefix:
Authorized Official - First Name:TAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:WEIDENBACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-746-3742
Mailing Address - Street 1:727A WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:WY
Mailing Address - Zip Code:82701-2930
Mailing Address - Country:US
Mailing Address - Phone:307-746-2425
Mailing Address - Fax:307-746-9263
Practice Address - Street 1:1124 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:NEWCASTLE
Practice Address - State:WY
Practice Address - Zip Code:82701-2972
Practice Address - Country:US
Practice Address - Phone:307-746-2425
Practice Address - Fax:307-746-9263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-29
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0002X, 333600000X
WYR101403336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2149854OtherPK
WY6369190002Medicare NSC