=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790180917
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NANCY ANNE KIRKWOOD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2014
-----------------------------------------------------
Last Update Date | 10/30/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 510 S HWY 89
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 83001-8507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-739-1164
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 9060
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 83002-9060
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-739-1164
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 1977
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------