Provider Demographics
NPI:1073653218
Name:MONTANA STATE UNIVERSITY
Entity Type:Organization
Organization Name:MONTANA STATE UNIVERSITY
Other - Org Name:MSU STUDENT HEALTH SERVICE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:STERNHAGEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:406-994-5498
Mailing Address - Street 1:MSU STUDENT HEALTH SERVICE RX
Mailing Address - Street 2:P.O.BOX 173260
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59717
Mailing Address - Country:US
Mailing Address - Phone:406-994-5498
Mailing Address - Fax:406-994-7071
Practice Address - Street 1:MSU STUDENT HEALTH SERVICE RX
Practice Address - Street 2:7TH AND GRANT
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-0002
Practice Address - Country:US
Practice Address - Phone:406-994-5498
Practice Address - Fax:406-994-7071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MTPHA-PHR-LIC-3903336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2049835OtherPK
MT000211055Medicaid