MEDICARE: GRANITE PHARMACY MISSOULA, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	3336C0003X	Community/Retail Pharmacy	18801	MT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PHA-PHR-LIC-18801	OTHER	MT	MT PHARMACY LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447683651
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRANITE PHARMACY MISSOULA, LLC

Provider Business Mailing Address
First Line	:	2230 27TH AVE. WEST
Second Line	:	SUITE 2
City	:	MISSOULA
State	:	MT
Zip	:	59804
Country	:	US
Telephone Number	:	406-926-2940
Fax Number	:	406-926-2944

Provider Business Practice Location Address
First Line	:	2230 27TH AVE. WEST
Second Line	:	SUITE 2
City	:	MISSOULA
State	:	MT
Zip	:	59804
Country	:	US
Telephone Number	:	406-926-2940
Fax Number	:	406-926-2944

Authorized Official
Title or Position	:	OWNER
Name	:	TINA KOERNER
Credential	:
Telephone Number	:	406-926-2941

Provider Enumeration Date	:	08/12/2013
Last Update Date	:	01/08/2026

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