Provider Demographics
NPI:1174915342
Name:CHEYENNE VA MEDICAL CENTER
Entity type:Organization
Organization Name:CHEYENNE VA MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OF PHARMACY
Authorized Official - Prefix:DR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:CORK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-432-3819
Mailing Address - Street 1:2360 E PERSHING BLVD
Mailing Address - Street 2:PHARMACY-119
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-5356
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2360 E PERSHING BLVD
Practice Address - Street 2:PHARMACY-119
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-5356
Practice Address - Country:US
Practice Address - Phone:307-996-4849
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-25
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3750286500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes286500000XHospitalsMilitary Hospital