Healthcare Provider Details

I. General information

NPI: 1649382565
Provider Name (Legal Business Name): VICKLUND INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 S 6TH ST
THERMOPOLIS WY
82443-3202
US

IV. Provider business mailing address

610 S 6TH ST
THERMOPOLIS WY
82443-3202
US

V. Phone/Fax

Practice location:
  • Phone: 307-864-2369
  • Fax: 307-864-9202
Mailing address:
  • Phone: 307-864-2369
  • Fax: 307-864-9202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberR10114
License Number StateWY

VIII. Authorized Official

Name: ANTHONY JOSEPH DEROMEDI
Title or Position: PRESIDENT
Credential:
Phone: 307-760-5192