Provider Demographics
NPI:1083946123
Name:MIRX LLC
Entity Type:Organization
Organization Name:MIRX LLC
Other - Org Name:MIRX PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-245-3575
Mailing Address - Street 1:993 S 24TH ST W
Mailing Address - Street 2:SUITE A
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102-7433
Mailing Address - Country:US
Mailing Address - Phone:406-869-6551
Mailing Address - Fax:406-869-6552
Practice Address - Street 1:993 S 24TH ST W
Practice Address - Street 2:SUITE A
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-7433
Practice Address - Country:US
Practice Address - Phone:406-869-6551
Practice Address - Fax:406-869-6552
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EMPLOYEE BENEFIT MANAGEMENT SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-30
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPHA-PHR-LIC-275863336C0003X, 3336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTPHA-PHR-LIC-27586OtherMONTANA STATE PHARMACY LICENSE