Provider Demographics
NPI:1073514428
Name:PLENTYWOOD DRUG INC.
Entity Type:Organization
Organization Name:PLENTYWOOD DRUG INC.
Other - Org Name:PLENTYWOOD REXALL DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:EBERLING
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:406-765-1810
Mailing Address - Street 1:119 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PLENTYWOOD
Mailing Address - State:MT
Mailing Address - Zip Code:59254-1817
Mailing Address - Country:US
Mailing Address - Phone:406-765-1810
Mailing Address - Fax:
Practice Address - Street 1:119 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PLENTYWOOD
Practice Address - State:MT
Practice Address - Zip Code:59254-1817
Practice Address - Country:US
Practice Address - Phone:406-765-1810
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT984332B00000X, 332BP3500X, 3336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT219219Medicaid
MT1073514428OtherMEDICARE