Healthcare Provider Details

I. General information

NPI: 1528073152
Provider Name (Legal Business Name): ROBERT DEAN WILCOX
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 03/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 GLACIER DR
LOLO MT
59847-8700
US

IV. Provider business mailing address

PO BOX 156
LOLO MT
59847-0156
US

V. Phone/Fax

Practice location:
  • Phone: 406-273-2322
  • Fax: 406-273-4208
Mailing address:
  • Phone: 406-273-2322
  • Fax: 406-273-4208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number137
License Number StateMT

VIII. Authorized Official

Name: ROBERT DEAN WILCOX
Title or Position: OWNER
Credential: RPH
Phone: 406-273-2322