Healthcare Provider Details

I. General information

NPI: 1073514428
Provider Name (Legal Business Name): PLENTYWOOD DRUG INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 01/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 N MAIN ST
PLENTYWOOD MT
59254-1817
US

IV. Provider business mailing address

119 N MAIN ST
PLENTYWOOD MT
59254-1817
US

V. Phone/Fax

Practice location:
  • Phone: 406-765-1810
  • Fax:
Mailing address:
  • Phone: 406-765-1810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number984
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number984
License Number StateMT
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number984
License Number StateMT
# 4
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number984
License Number StateMT

VIII. Authorized Official

Name: MR. MARVIN A EBERLING
Title or Position: OWNER
Credential: R.PH
Phone: 406-765-1810