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General NPI Number Information
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NPI Number | 1881777696
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Entity Type | Organization
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Legal Business Name | HILLSIDE PHARMACY
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Dates
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Enumeration Date | 10/23/2006
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Last Update Date | 06/19/2008
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Provider Practice Location Address
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Address Line | 224 MAIN STREET
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City | SUNDANCE
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State | WY
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Zip | 82729-0547
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Country | US
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Telephone | 307-283-3883
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Fax | 307-283-3884
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Provider Business Mailing Address
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Address Line | PO BOX 547
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City | SUNDANCE
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State | WY
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Zip | 82729-0547
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Country | US
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Telephone | 307-283-3883
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Fax | 307-283-3884
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Authorized Official
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Title or Position | PHARMACIST/OWNER
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Name | MR. VIRGIL VIRCHOW
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Credential |
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Telephone | 307-283-3883
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 5201013
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License Number State | WY
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