Provider Demographics
NPI:1023154564
Name:STATE OF WYOMING
Entity type:Organization
Organization Name:STATE OF WYOMING
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MGR
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KULOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-335-6762
Mailing Address - Street 1:8204 STATE HIGHWAY 789
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-2941
Mailing Address - Country:US
Mailing Address - Phone:307-335-6719
Mailing Address - Fax:307-335-6987
Practice Address - Street 1:8204 STATE HIGHWAY 789
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-2941
Practice Address - Country:US
Practice Address - Phone:307-335-6719
Practice Address - Fax:307-335-6987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5202926IP3336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY100180901Medicaid
WY100180900Medicaid
2111516OtherPK