Provider Demographics
NPI:1700961083
Name:MEDICAL CENTER PHARMACY LLC
Entity Type:Organization
Organization Name:MEDICAL CENTER PHARMACY LLC
Other - Org Name:MEDICAL CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:WENKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-527-6221
Mailing Address - Street 1:698 YELLOWSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-9322
Mailing Address - Country:US
Mailing Address - Phone:307-527-6221
Mailing Address - Fax:307-527-6667
Practice Address - Street 1:698 YELLOWSTONE AVE
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-9322
Practice Address - Country:US
Practice Address - Phone:307-527-6221
Practice Address - Fax:307-527-6667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
WY52022053336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY104027800Medicaid
2111345OtherPK
WY0384990001Medicare NSC