MEDICARE: LJC,INC DBA STONE DRUG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	52-02356	WY
2	332B00000X	Durable Medical Equipment & Medical Supplies		WY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	52-02356	OTHER	WY	WY RETAIL PHARMACY LICENS
2	1500	OTHER	WY	WY WHOLESALER-DISTRIBUTER

General Provider Information

NPI Number	:	1003943176
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LJC,INC DBA STONE DRUG

Provider Business Mailing Address
First Line	:	PO BOX 9000
Second Line	:	830 WEST BROADWAY
City	:	JACKSON
State	:	WY
Zip	:	83002-9000
Country	:	US
Telephone Number	:	307-733-9768
Fax Number	:

Provider Business Practice Location Address
First Line	:	830 WEST BROADWAY
Second Line	:	BOX 9000
City	:	JACKSON
State	:	WY
Zip	:	83001
Country	:	US
Telephone Number	:	307-733-9768
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT, PIC
Name	:	MR. JOHN FISHER CROOK
Credential	:	RPH
Telephone Number	:	307-733-9768

Provider Enumeration Date	:	02/27/2007
Last Update Date	:	03/07/2023

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