Healthcare Provider Details

I. General information

NPI: 1851062079
Provider Name (Legal Business Name): CAMILLA HANCOCK PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2021
Last Update Date: 09/27/2021
Certification Date: 09/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W C ST
BASIN WY
82410-5052
US

IV. Provider business mailing address

4350 ROAD 16 1/2
OTTO WY
82434-9714
US

V. Phone/Fax

Practice location:
  • Phone: 307-568-3636
  • Fax:
Mailing address:
  • Phone: 307-271-1095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number4200
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: