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: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 S HOLLAND ST
PHILIPSBURG MT
59858-7609
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: 406-926-2941
  • Fax: 844-589-6696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number1316
License Number StateMT
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

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