Healthcare Provider Details

I. General information

NPI: 1962823054
Provider Name (Legal Business Name): VENDOR PRO CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2013
Last Update Date: 05/26/2020
Certification Date: 05/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1627 W MAIN ST. SUITE 446
BOZEMAN MT
59715-4011
US

IV. Provider business mailing address

1627 W MAIN ST. SUITE 446
BOZEMAN MT
59715-4011
US

V. Phone/Fax

Practice location:
  • Phone: 406-219-1922
  • Fax: 406-219-1953
Mailing address:
  • Phone: 406-219-1922
  • Fax: 406-219-1953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHA-WDD-LIC-21852
License Number StateMT

VIII. Authorized Official

Name: MR. TYLER D BOHANNON
Title or Position: MANAGER
Credential:
Phone: 406-219-1922