Healthcare Provider Details

I. General information

NPI: 1831512342
Provider Name (Legal Business Name): MINING CITY COMPOUNDING PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2014
Last Update Date: 03/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

327 S EXCELSIOR AVE
BUTTE MT
59701-1536
US

IV. Provider business mailing address

327 S EXCELSIOR AVE
BUTTE MT
59701-1536
US

V. Phone/Fax

Practice location:
  • Phone: 406-723-3308
  • Fax: 406-782-8243
Mailing address:
  • Phone: 406-723-3308
  • Fax: 406-782-8243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number21476
License Number StateMT

VIII. Authorized Official

Name: CHAD OCONNELL
Title or Position: OWNER/OPERATOR
Credential:
Phone: 406-723-3308