Provider Demographics
NPI:1104229426
Name:WYOMING MEDICINE AND PHARMACY LLC
Entity type:Organization
Organization Name:WYOMING MEDICINE AND PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:F
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-468-5065
Mailing Address - Street 1:443 SPRING ST
Mailing Address - Street 2:SUITE 303
Mailing Address - City:JEFFERSONVLLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-4494
Mailing Address - Country:US
Mailing Address - Phone:812-913-4416
Mailing Address - Fax:812-213-8408
Practice Address - Street 1:443 SPRING ST
Practice Address - Street 2:SUITE 303
Practice Address - City:JEFFERSONVLLE
Practice Address - State:IN
Practice Address - Zip Code:47130-4494
Practice Address - Country:US
Practice Address - Phone:812-913-4416
Practice Address - Fax:812-213-8408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-01
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty