Healthcare Provider Details

I. General information

NPI: 1982027876
Provider Name (Legal Business Name): CDE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2014
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 10TH ST
EVANSTON WY
82930-3421
US

IV. Provider business mailing address

131 10TH ST
EVANSTON WY
82930-3421
US

V. Phone/Fax

Practice location:
  • Phone: 307-789-4000
  • Fax: 307-444-4000
Mailing address:
  • Phone: 307-789-4000
  • Fax: 307-444-4000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberR10068
License Number StateWY

VIII. Authorized Official

Name: ANDREW CANNON
Title or Position: MANAGER
Credential:
Phone: 307-789-4000