Healthcare Provider Details

I. General information

NPI: 1316087299
Provider Name (Legal Business Name): PROFESSIONAL PHARMACY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 02/10/2022
Certification Date: 02/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 CONSTITUTION AVE.
SARATOGA WY
82331
US

IV. Provider business mailing address

PO BOX 683
SARATOGA WY
82331-0683
US

V. Phone/Fax

Practice location:
  • Phone: 307-326-5129
  • Fax: 307-326-5165
Mailing address:
  • Phone:
  • Fax: 307-326-5165

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 Number52-03120
License Number StateWY

VIII. Authorized Official

Name: ROD WAECKERLIN
Title or Position: OWNER/RPH
Credential:
Phone: 307-320-8482