Healthcare Provider Details

I. General information

NPI: 1407361736
Provider Name (Legal Business Name): MOTHERS' MILK BANK OF MONTANA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2017
Last Update Date: 12/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2825 STOCKYARD RD STE C1
MISSOULA MT
59808-1502
US

IV. Provider business mailing address

2825 STOCKYARD RD STE C1
MISSOULA MT
59808-1502
US

V. Phone/Fax

Practice location:
  • Phone: 406-531-6789
  • Fax: 888-287-1423
Mailing address:
  • Phone: 406-531-6789
  • Fax: 888-287-1423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL

VIII. Authorized Official

Name: JESSICA WELBORN
Title or Position: EXECUTIVE DIRECTOR
Credential: PHD
Phone: 406-531-6789