Provider Demographics
NPI:1043375975
Name:BITTERROOT DRUG INC
Entity Type:Organization
Organization Name:BITTERROOT DRUG INC
Other - Org Name:BITTERROOT DRUG INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETE
Authorized Official - Middle Name:
Authorized Official - Last Name:SEIFERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-363-3611
Mailing Address - Street 1:211 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MT
Mailing Address - Zip Code:59840-2553
Mailing Address - Country:US
Mailing Address - Phone:406-363-3611
Mailing Address - Fax:406-363-0131
Practice Address - Street 1:211 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MT
Practice Address - Zip Code:59840-2553
Practice Address - Country:US
Practice Address - Phone:406-363-3611
Practice Address - Fax:406-363-0131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X, 3336L0003X, 3336M0002X, 332B00000X
MT11603336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT562819Medicaid
MT0222534Medicaid
2049918OtherPK
ID805686700Medicaid