Provider Demographics
NPI:1427661032
Name:BACA, DAVID JAMESON (PHARM D)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:JAMESON
Last Name:BACA
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 1/2 N 11TH ST
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82072-2740
Mailing Address - Country:US
Mailing Address - Phone:562-309-5670
Mailing Address - Fax:
Practice Address - Street 1:580 LIVINGSTON AVE
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82007-1966
Practice Address - Country:US
Practice Address - Phone:307-823-6812
Practice Address - Fax:307-823-6813
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY4652183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist