Provider Demographics
NPI:1114245867
Name:SWEETWATER, LLC
Entity Type:Organization
Organization Name:SWEETWATER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMURRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-541-0420
Mailing Address - Street 1:5707 W HARRIER DR
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-5345
Mailing Address - Country:US
Mailing Address - Phone:406-541-0420
Mailing Address - Fax:
Practice Address - Street 1:5707 W HARRIER DR
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-5345
Practice Address - Country:US
Practice Address - Phone:406-541-0420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-05
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBL20100152332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site