Healthcare Provider Details

I. General information

NPI: 1205905502
Provider Name (Legal Business Name): GLENDIVE MEDICAL CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 03/04/2021
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 PROSPECT DR
GLENDIVE MT
59330-1943
US

IV. Provider business mailing address

202 PROSPECT DR
GLENDIVE MT
59330-1943
US

V. Phone/Fax

Practice location:
  • Phone: 406-345-3306
  • Fax: 406-345-3358
Mailing address:
  • Phone: 406-345-3306
  • Fax: 406-345-3358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number134
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number134
License Number StateMT

VIII. Authorized Official

Name: WILLIAM ROBINSON
Title or Position: VP OF FINANCIAL SERVICES
Credential:
Phone: 406-345-8924