Provider Demographics
NPI:1003841016
Name:TIMBER RIDGE PHARMACY
Entity Type:Organization
Organization Name:TIMBER RIDGE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACY TECH
Authorized Official - Prefix:
Authorized Official - First Name:LANS
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:IV
Authorized Official - Credentials:
Authorized Official - Phone:406-363-9003
Mailing Address - Street 1:1131 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MT
Mailing Address - Zip Code:59840-2150
Mailing Address - Country:US
Mailing Address - Phone:406-363-9003
Mailing Address - Fax:406-363-9005
Practice Address - Street 1:1131 N 1ST ST
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MT
Practice Address - Zip Code:59840-2150
Practice Address - Country:US
Practice Address - Phone:406-363-9003
Practice Address - Fax:406-363-9005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
MT10973336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT5607030Medicaid
MT0213408Medicaid
MT0213408Medicaid