Provider Demographics
NPI:1104378439
Name:SHIELDS LLC
Entity Type:Organization
Organization Name:SHIELDS LLC
Other - Org Name:406 CLINIC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ PIC
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-541-4060
Mailing Address - Street 1:4108 LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-3046
Mailing Address - Country:US
Mailing Address - Phone:406-541-4060
Mailing Address - Fax:406-541-9699
Practice Address - Street 1:1315 WYOMING ST STE A
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-1725
Practice Address - Country:US
Practice Address - Phone:406-544-8808
Practice Address - Fax:406-541-0185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-03
Last Update Date:2018-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336I0012X
MT427903336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2166083OtherPK