Healthcare Provider Details

I. General information

NPI: 1659590172
Provider Name (Legal Business Name): ROCKY MOUNTAIN PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 N WILLSON AVE SUITE C
BOZEMAN MT
59715-3585
US

IV. Provider business mailing address

25 N WILLSON AVE SUITE C
BOZEMAN MT
59715-3585
US

V. Phone/Fax

Practice location:
  • Phone: 406-587-4332
  • Fax:
Mailing address:
  • Phone: 406-587-4332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number1015
License Number StateMT

VII. Legacy identifiers

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

# 1
Identifier0211769
Identifier TypeMEDICAID
Identifier StateMT
Identifier Issuer

VIII. Authorized Official

Name: DR. HOLLY G ROTAR
Title or Position: PHARMACIST
Credential: PHARM.D., MBA
Phone: 406-587-4332