Healthcare Provider Details

I. General information

NPI: 1316953102
Provider Name (Legal Business Name): LARRY'S IGA PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 S. PARK STREET
BROADUS MT
59317
US

IV. Provider business mailing address

PO BOX 549 120 S. PARK STREET
BROADUS MT
59317
US

V. Phone/Fax

Practice location:
  • Phone: 406-436-2270
  • Fax: 406-436-2338
Mailing address:
  • Phone: 406-436-2270
  • Fax: 406-436-2338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number711
License Number StateMT

VIII. Authorized Official

Name: MR. JOHN LAWRENCE LANE
Title or Position: PHARMACY MANAGER
Credential: RPH.
Phone: 406-436-2270