Healthcare Provider Details

I. General information

NPI: 1881777696
Provider Name (Legal Business Name): HILLSIDE PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 MAIN STREET
SUNDANCE WY
82729-0547
US

IV. Provider business mailing address

PO BOX 547
SUNDANCE WY
82729-0547
US

V. Phone/Fax

Practice location:
  • Phone: 307-283-3883
  • Fax: 307-283-3884
Mailing address:
  • Phone: 307-283-3883
  • Fax: 307-283-3884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5201013
License Number StateWY

VIII. Authorized Official

Name: MR. VIRGIL VIRCHOW
Title or Position: PHARMACIST/OWNER
Credential:
Phone: 307-283-3883