Healthcare Provider Details

I. General information

NPI: 1417264649
Provider Name (Legal Business Name): GRANITE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2010
Last Update Date: 02/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 N. MONTGOMERY ST
PHILIPSBURG MT
59858
US

IV. Provider business mailing address

2230 27TH AVE
MISSOULA MT
59804-5126
US

V. Phone/Fax

Practice location:
  • Phone: 406-859-3784
  • Fax: 406-859-4412
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 TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number1316
License Number StateMT

VIII. Authorized Official

Name: ROBERT BEYER
Title or Position: OWNER/PRESIDENT
Credential:
Phone: 406-926-2940