Pharmacy Help Desk: 1-877-209-1264, Provider PA Help Desk: 1-877-207-1126

Update Pharmacy Provider Information

To Update: Complete:
*If document is listed in red, then ORIGINAL documents must be returned.
  • Pharmacy Information Including:
    • Legal Business Name
    • Address
    • Phone Number
    • Fax Number
    • Contact Person

Medicaid Pharmacy Provider Updates Form

→ Return by email, fax or mail (see Contact Information below)

  • PIC (Pharmacist-in-Charge)
  • Managing/Directing Employee

Medicaid Pharmacy Updates – Pharmacist & Managing/Directing Employee Form

→ Return by fax or mail (see Contact Information below)

  • Board Members
  • % Change in Ownership (Must be updated with Change Healthcare anytime an individual/organization is added/removed who has direct/indirect ownership interests, or controlling interest separately or in combination amounting to an ownership interest of 5% or more in the pharmacy.)

Wyoming Pharmacy Provider – Change in % Ownership or Board Members

→ Return by fax or mail (see Contact Information below)

  • Ownership (due to buyout, etc.)
  • NPI
  • NCPDP/NABP#

Enrollment Application

  • Tax ID

Medicaid Pharmacy Provider Updates Form & Wyoming Vendor Management Form (VMF)

→ Return by mail (see Contact Information below)

  • Banking Information, including:
    • Electronic Funds Transfer (EFT) account/routing #

Wyoming Vendor Management Form (VMF) (as well as ORIGINAL Form W-9 & ORIGINAL bank letter or ORIGINAL voided check)

→ Return by mail (see Contact Information below)

***The information provided on the Vendor Management Form must match that provided on the Form W-9 and both forms must be ORIGINAL with ORIGINAL signatures. Please use the current Form W-9, found at http://www.irs.gov/pub/irs-pdf/fw9.pdf. These forms must be accompanied by an ORIGINAL VOIDED check or an ORIGINAL letter from your Financial Institution.

***The State of Wyoming will only accept 1) an ORIGINAL/unused VOIDED check; or 2) an ORIGINAL letter from your Financial Institution on Financial Institution letterhead, with a date not older than 1 year, signed by a bank representative, including the vendor/business name, routing #, account #, and account type (e.g. checking or savings).

→ PLEASE NOTE: The business name, address, and information must be consistent across the VMF, the W-9, and the check/bank letter. Please follow the “Wyoming State Auditor’s Office Instructions for Wyoming Vendor Management Form” found on the page before the VMF.

  • Users for Change Healthcare Electronic Data Interchange (EDI) Gateway to download 835s/RAs (add/remove/edit users)

Change Healthcare EDI Access Form

→ Return by email, fax or mail (see Contact Information below)

For any of the following reasons: Contact Change Healthcare
  • Change in Ownership
  • Pharmacy Closure

Phone: (877) 205-8083

Contact Information:

Phone: (877) 205-8083
Email: PBA_wyprovider@changehealthcare.com
Fax: (307) 426-4169
Mail: Change Healthcare
Attn: Wyoming Pharmacy Provider Enrollment
PO Box 21719
Cheyenne, WY 82003