Provider Demographics
NPI:1962940114
Name:SOUTH LINCOLN HOSPITAL DISTRICT
Entity type:Organization
Organization Name:SOUTH LINCOLN HOSPITAL DISTRICT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/AO
Authorized Official - Prefix:
Authorized Official - First Name:KEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ARCHER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:307-877-4401
Mailing Address - Street 1:613 MOOSE ST
Mailing Address - Street 2:
Mailing Address - City:KEMMERER
Mailing Address - State:WY
Mailing Address - Zip Code:83101-3519
Mailing Address - Country:US
Mailing Address - Phone:307-800-8880
Mailing Address - Fax:307-800-8881
Practice Address - Street 1:613 MOOSE ST
Practice Address - Street 2:
Practice Address - City:KEMMERER
Practice Address - State:WY
Practice Address - Zip Code:83101-3519
Practice Address - Country:US
Practice Address - Phone:307-800-8880
Practice Address - Fax:307-800-8881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-08
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
WYR101623336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2167554OtherPK