Healthcare Provider Details

I. General information

NPI: 1770744583
Provider Name (Legal Business Name): PHARMACEUTICAL COMPOUNDING SPECIALISTS OF WYOMING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2008
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2546 E 2ND ST BLDG#100
CASPER WY
82609-2062
US

IV. Provider business mailing address

2546 E 2ND ST BLDG#100
CASPER WY
82609-2062
US

V. Phone/Fax

Practice location:
  • Phone: 307-472-0597
  • Fax: 307-237-7748
Mailing address:
  • Phone: 307-472-0597
  • Fax: 307-237-7748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number5282609A
License Number StateWY

VIII. Authorized Official

Name: MR. RICHARD L JOHNSON
Title or Position: OWNER
Credential:
Phone: 307-472-0597