MEDICARE: ROBERT DEAN WILCOX

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	137	MT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2702555	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1528073152
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROBERT DEAN WILCOX

Provider Business Mailing Address
First Line	:	PO BOX 156
Second Line	:
City	:	LOLO
State	:	MT
Zip	:	59847-0156
Country	:	US
Telephone Number	:	406-273-2322
Fax Number	:	406-273-4208

Provider Business Practice Location Address
First Line	:	103 GLACIER DR
Second Line	:
City	:	LOLO
State	:	MT
Zip	:	59847-8700
Country	:	US
Telephone Number	:	406-273-2322
Fax Number	:	406-273-4208

Authorized Official
Title or Position	:	OWNER
Name	:	ROBERT DEAN WILCOX
Credential	:	RPH
Telephone Number	:	406-273-2322

Provider Enumeration Date	:	07/30/2006
Last Update Date	:	03/23/2010

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