Healthcare Provider Details

I. General information

NPI: 1912462326
Provider Name (Legal Business Name): UINTA DRUG PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2019
Last Update Date: 09/06/2023
Certification Date: 03/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2822 WY 414 STE C
LYMAN WY
82937
US

IV. Provider business mailing address

2822 HIGHWAY 414
LYMAN WY
82937-9135
US

V. Phone/Fax

Practice location:
  • Phone: 307-786-2222
  • Fax: 866-846-7151
Mailing address:
  • Phone: 307-786-2222
  • Fax: 866-846-7151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: BRYCE HABEL
Title or Position: PHARMACIST IN CHARGE
Credential: PHARMD
Phone: 307-786-2222