Healthcare Provider Details

I. General information

NPI: 1104422849
Provider Name (Legal Business Name): CRAIG C ERICKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2020
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 N BROADWAY AVE
RED LODGE MT
59068-9132
US

IV. Provider business mailing address

PO BOX 1030
RED LODGE MT
59068-1030
US

V. Phone/Fax

Practice location:
  • Phone: 406-446-1017
  • Fax: 406-446-2516
Mailing address:
  • Phone: 406-446-1017
  • Fax: 406-446-2516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number3470
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: