MEDICARE: MINING CITY COMPOUNDING PHARMACY 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	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	21476	MT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2144257	OTHER		PK

General Provider Information

NPI Number	:	1831512342
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINING CITY COMPOUNDING PHARMACY LLC

Provider Business Mailing Address
First Line	:	327 S EXCELSIOR AVE
Second Line	:
City	:	BUTTE
State	:	MT
Zip	:	59701-1536
Country	:	US
Telephone Number	:	406-723-3308
Fax Number	:	406-782-8243

Provider Business Practice Location Address
First Line	:	327 S EXCELSIOR AVE
Second Line	:
City	:	BUTTE
State	:	MT
Zip	:	59701-1536
Country	:	US
Telephone Number	:	406-723-3308
Fax Number	:	406-782-8243

Authorized Official
Title or Position	:	OWNER/OPERATOR
Name	:	CHAD OCONNELL
Credential	:
Telephone Number	:	406-723-3308

Provider Enumeration Date	:	02/04/2014
Last Update Date	:	03/07/2014

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