Healthcare Provider Details

I. General information

NPI: 1972657179
Provider Name (Legal Business Name): TETON COUNTY HOSPITAL DISTRICT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 12/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 E BROADWAY AVE
JACKSON WY
83001-8642
US

IV. Provider business mailing address

PO BOX 428
JACKSON WY
83001-0428
US

V. Phone/Fax

Practice location:
  • Phone: 307-739-6172
  • Fax: 307-739-7698
Mailing address:
  • Phone: 307-739-6172
  • Fax: 307-739-7698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number5201102
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number5201102
License Number StateWY

VIII. Authorized Official

Name: ALISA JEAN LANE
Title or Position: DIRECTOR OF FINANCE
Credential:
Phone: 307-739-7641