Zachary Jack Ivie
Individual provider Active NPI Pharmacist · Afton, WY
NPI 1114335205 · NPPES record last updated Aug 22, 2016
Key facts
- NPI
- 1114335205
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Pharmacist 183500000X
- License
- 3757 (WY)
- Practice address
- 679 S Washington St
Afton, WY 83110-6000 - Phone
- (307) 885-9804
- Fax
- (307) 885-9760
- NPI assigned
- Aug 1, 2014
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 2
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| P7041 | ID | MD | Pharmacist |
| 3757 | WY | MD | Pharmacist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Shopko Stores Operating Co LLC | Past | Accepting new patients | |
| Shopko Stores Operating Co. LLC | Past | Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | P7041 | ID | |
| Pharmacist | 183500000X | 3757 | WY | Yes |
Addresses
Primary practice location
679 S Washington St
Afton, WY 83110-6000
Mailing address
679 S Washington St
Afton, WY 83110-6000
Phone (307) 885-9804
Other providers in Afton, WY
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 22, 2016. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.