Healthcare Provider Details

I. General information

NPI: 1588725782
Provider Name (Legal Business Name): UTTERBACK RX INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 03/24/2022
Certification Date: 03/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 4TH AVE SE
CONRAD MT
59425-2327
US

IV. Provider business mailing address

5 4TH AVE SE
CONRAD MT
59425-2327
US

V. Phone/Fax

Practice location:
  • Phone: 406-278-3261
  • Fax: 406-278-9936
Mailing address:
  • Phone: 406-278-3261
  • Fax: 406-278-9936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number20411
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: LOREN OR BRANDON UTTERBACK
Title or Position: CO-OWNERS
Credential:
Phone: 406-278-3261