Healthcare Provider Details

I. General information

NPI: 1003995788
Provider Name (Legal Business Name): BUFFALO PRESCRIPTION SHOP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 10/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

431 FORT ST
BUFFALO WY
82834-1805
US

IV. Provider business mailing address

431 FORT ST
BUFFALO WY
82834-1805
US

V. Phone/Fax

Practice location:
  • Phone: 307-684-7003
  • Fax: 307-684-7348
Mailing address:
  • Phone: 307-684-7003
  • Fax: 307-684-7348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5200112
License Number StateWY

VIII. Authorized Official

Name: TOM ALLEN MAERTENS
Title or Position: OWNER/PHARMACIST-IN-CHARGE
Credential: RPH.
Phone: 307-684-7003