Provider Demographics
NPI:1215781000
Name:SOUTH STREET PHARMACY, LLC
Entity type:Organization
Organization Name:SOUTH STREET PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:MRS
Authorized Official - First Name:CORINDA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GEILE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:307-331-2784
Mailing Address - Street 1:1456 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:WHEATLAND
Mailing Address - State:WY
Mailing Address - Zip Code:82201-2736
Mailing Address - Country:US
Mailing Address - Phone:307-322-2486
Mailing Address - Fax:307-322-2487
Practice Address - Street 1:1456 SOUTH ST
Practice Address - Street 2:
Practice Address - City:WHEATLAND
Practice Address - State:WY
Practice Address - Zip Code:82201-2736
Practice Address - Country:US
Practice Address - Phone:307-322-2486
Practice Address - Fax:307-322-2487
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTH STREET PHARMACY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-04-16
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy