Healthcare Provider Details

I. General information

NPI: 1508426081
Provider Name (Legal Business Name): PIONEER PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2019
Last Update Date: 06/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

832 W MAIN ST
RIVERTON WY
82501-3342
US

IV. Provider business mailing address

131 8 MILE RD
RIVERTON WY
82501-9774
US

V. Phone/Fax

Practice location:
  • Phone: 307-463-8400
  • Fax: 307-463-8401
Mailing address:
  • Phone: 307-463-8400
  • Fax: 307-463-8401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. SOMMER PEDERSEN
Title or Position: OWNER AND MANAGER
Credential: PHARMD
Phone: 307-463-8400