Provider Demographics
NPI:1770744583
Name:PHARMACEUTICAL COMPOUNDING SPECIALISTS OF WYOMING
Entity type:Organization
Organization Name:PHARMACEUTICAL COMPOUNDING SPECIALISTS OF WYOMING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-472-0597
Mailing Address - Street 1:2546 E 2ND ST
Mailing Address - Street 2:BLDG#100
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-2062
Mailing Address - Country:US
Mailing Address - Phone:307-472-0597
Mailing Address - Fax:307-237-7748
Practice Address - Street 1:2546 E 2ND ST
Practice Address - Street 2:BLDG#100
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-2062
Practice Address - Country:US
Practice Address - Phone:307-472-0597
Practice Address - Fax:307-237-7748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-24
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5282609A3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy