1770043234 NPI number — BVP LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770043234 NPI number — BVP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BVP LLC
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:
CITY DRUG OF BRIDGER VALLEY
Provider Other Organization Name Type Code:
3
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:
1770043234
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1699
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVANSTON
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82931
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-782-3784
Provider Business Mailing Address Fax Number:
307-782-3785

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
950 N HWY 414
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNTAIN VIEW
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82939
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-782-3784
Provider Business Practice Location Address Fax Number:
307-782-3785
Provider Enumeration Date:
03/21/2019

Additional Information

Authorized Official

Authorized Official Last Name:
CANNON
Authorized Official First Name:
ANDREW
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
307-789-4000

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: R10181 . This is a "STATE PHARMACY LICENSE" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 153007100 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".




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