Provider Demographics
NPI:1225140221
Name:WESTERN DRUG PHARMACY
Entity Type:Organization
Organization Name:WESTERN DRUG PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELCEY
Authorized Official - Middle Name:
Authorized Official - Last Name:DIEMERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-265-9601
Mailing Address - Street 1:PO BOX 631
Mailing Address - Street 2:
Mailing Address - City:HAVRE
Mailing Address - State:MT
Mailing Address - Zip Code:59501-0631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:123 5TH AVE
Practice Address - Street 2:STE B
Practice Address - City:HAVRE
Practice Address - State:MT
Practice Address - Zip Code:59501-3624
Practice Address - Country:US
Practice Address - Phone:406-265-9601
Practice Address - Fax:406-265-4422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
MT11373336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0213486Medicaid
2764226OtherOTHER ID NUMBER
2764226OtherOTHER ID NUMBER