MEDICARE: MINERAL PHARMACY INC

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	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	49935	MT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2050377	OTHER		PK

General Provider Information

NPI Number	:	1871695213
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINERAL PHARMACY INC

Provider Business Mailing Address
First Line	:	207 RIVER ST
Second Line	:
City	:	SUPERIOR
State	:	MT
Zip	:	59872-9673
Country	:	US
Telephone Number	:	406-822-4681
Fax Number	:	406-822-0057

Provider Business Practice Location Address
First Line	:	207 RIVER ST
Second Line	:
City	:	SUPERIOR
State	:	MT
Zip	:	59872-9673
Country	:	US
Telephone Number	:	406-822-4681
Fax Number	:	406-822-0057

Authorized Official
Title or Position	:	OWNER/VP
Name	:	DAVID BURNETT
Credential	:
Telephone Number	:	406-822-4681

Provider Enumeration Date	:	09/05/2006
Last Update Date	:	07/19/2018

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Directions to “MINERAL PHARMACY INC ” Practice Location

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