Healthcare Provider Details

I. General information

NPI: 1669501649
Provider Name (Legal Business Name): LODGE GRASS HEALTH CENTER PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HARDING AVE
LODGE GRASS MT
59050
US

IV. Provider business mailing address

HARDING AVE PO BOX 780
LODGE GRASS MT
59050
US

V. Phone/Fax

Practice location:
  • Phone: 406-639-2317
  • Fax: 406-639-2976
Mailing address:
  • Phone: 406-639-2317
  • Fax: 406-639-2976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number
License Number StateNULL

VIII. Authorized Official

Name: CYNTHIA LARSEN
Title or Position: AREA BUSINESS OFFICE COORDINATOR
Credential:
Phone: 406-247-7184