Healthcare Provider Details

I. General information

NPI: 1033123989
Provider Name (Legal Business Name): THE DRUG STORE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 S. MAIN ST.
LYMAN WY
82937
US

IV. Provider business mailing address

PO BOX 1700 106 S. MAIN ST.
LYMAN WY
82937
US

V. Phone/Fax

Practice location:
  • Phone: 307-787-6756
  • Fax: 307-787-3792
Mailing address:
  • Phone: 307-787-6756
  • Fax: 307-787-3792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number1731
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5202407
License Number StateWY

VIII. Authorized Official

Name: MR. ROBERT B. AVERY
Title or Position: PRESIDENT
Credential: RPH
Phone: 307-787-6756