Healthcare Provider Details

I. General information

NPI: 1962940114
Provider Name (Legal Business Name): SOUTH LINCOLN HOSPITAL DISTRICT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2017
Last Update Date: 03/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 MOOSE ST
KEMMERER WY
83101-3519
US

IV. Provider business mailing address

613 MOOSE ST
KEMMERER WY
83101-3519
US

V. Phone/Fax

Practice location:
  • Phone: 307-800-8880
  • Fax: 307-800-8881
Mailing address:
  • Phone: 307-800-8880
  • Fax: 307-800-8881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberR10162
License Number StateWY
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: KEN ARCHER
Title or Position: CEO/AO
Credential: RPH
Phone: 307-877-4401