1720077837 NPI number — EXPRESS PHARMACY

Table of content: (NPI 1720077837)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720077837 NPI number — EXPRESS PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EXPRESS PHARMACY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720077837
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4005 E GRAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LARAMIE
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82070-5161
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-745-1557
Provider Business Mailing Address Fax Number:
307-742-0787

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4005 E GRAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LARAMIE
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82070-5161
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-745-1557
Provider Business Practice Location Address Fax Number:
307-742-0787
Provider Enumeration Date:
10/20/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ATHEY
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
307-745-1557

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  5203485 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)