Healthcare Provider Details

I. General information

NPI: 1750551966
Provider Name (Legal Business Name): MONTANA CVS PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2008
Last Update Date: 04/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1311 GRAND AVE
BILLINGS MT
59102-3101
US

IV. Provider business mailing address

1 CVS DR BOX 1075 PHARMACY ENROLLMENTS
WOONSOCKET RI
02895-6146
US

V. Phone/Fax

Practice location:
  • Phone: 406-259-7034
  • Fax:
Mailing address:
  • Phone: 401-765-1500
  • Fax: 401-770-7108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2783339
Identifier TypeOTHER
Identifier StateMT
Identifier IssuerNCPDP
# 2
Identifier1750551966
Identifier TypeMEDICAID
Identifier StateMT
Identifier Issuer

VIII. Authorized Official

Name: SUSAN COLBERT
Title or Position: DIRECTOR, PAYER RELATIONS
Credential:
Phone: 401-770-2751