Healthcare Provider Details

I. General information

NPI: 1104965003
Provider Name (Legal Business Name): POWELL VALLEY HEALTH CARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 03/07/2023
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 AVENUE H
POWELL WY
82435-2260
US

IV. Provider business mailing address

777 AVENUE H
POWELL WY
82435-2260
US

V. Phone/Fax

Practice location:
  • Phone: 307-754-1125
  • Fax: 307-754-1176
Mailing address:
  • Phone: 307-754-1125
  • Fax: 307-754-1176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number5201342
License Number StateWY
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number5201342
License Number StateWY

VIII. Authorized Official

Name: MS. TERRY ODOM
Title or Position: CEO
Credential: CEO
Phone: 307-754-1179