Healthcare Provider Details

I. General information

NPI: 1447683651
Provider Name (Legal Business Name): GRANITE PHARMACY MISSOULA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2013
Last Update Date: 06/23/2025
Certification Date: 06/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2230 27TH AVE. WEST SUITE 2
MISSOULA MT
59804
US

IV. Provider business mailing address

2230 27TH AVE. WEST SUITE 2
MISSOULA MT
59804
US

V. Phone/Fax

Practice location:
  • Phone: 406-926-2940
  • Fax: 406-926-2944
Mailing address:
  • Phone: 406-926-2940
  • Fax: 406-926-2944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number18801
License Number StateMT

VIII. Authorized Official

Name: TINA KOERNER
Title or Position: CEO
Credential:
Phone: 406-926-2941