Provider Demographics
NPI:1073853941
Name:VANS IGA OF DILLON INC
Entity Type:Organization
Organization Name:VANS IGA OF DILLON INC
Other - Org Name:VANS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:REBISH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-988-7121
Mailing Address - Street 1:110 SOUTHSIDE BLVD
Mailing Address - Street 2:
Mailing Address - City:DILLON
Mailing Address - State:MT
Mailing Address - Zip Code:59725-3536
Mailing Address - Country:US
Mailing Address - Phone:406-988-7121
Mailing Address - Fax:406-683-3540
Practice Address - Street 1:110 SOUTHSIDE BLVD
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:MT
Practice Address - Zip Code:59725-3536
Practice Address - Country:US
Practice Address - Phone:406-988-7121
Practice Address - Fax:406-683-3540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-28
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
MTPHAPHRLIC148053336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2139191OtherPK
MT610084Medicaid