=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720355605
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFREY EDWARD GOLDBERG PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2011
-----------------------------------------------------
Last Update Date | 11/21/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1525 W PARK AVE
-----------------------------------------------------
City | ANACONDA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59711-1829
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-563-8410
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2000 TAMMANY ST
-----------------------------------------------------
City | ANACONDA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59711-1752
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-560-1857
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 6866
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------