Provider Demographics
NPI:1326564857
Name:BILLINGS CLINIC SPECIALTY SUPPLIES AND SERVICES, LLC
Entity Type:Organization
Organization Name:BILLINGS CLINIC SPECIALTY SUPPLIES AND SERVICES, LLC
Other - Org Name:BILLINGS CLINIC SPECIALTY SUPPLIES
Other - Org Type:Other Name
Authorized Official - Title/Position:VICE PRESIDENT, CHIEF FINANCIAL OFF
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PREWITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-657-4546
Mailing Address - Street 1:1015 BROADWATER AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102-5446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1015 BROADWATER AVE STE 101
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102
Practice Address - Country:US
Practice Address - Phone:406-657-4545
Practice Address - Fax:406-435-6393
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BILLINGS CLINIC SPECIALTY SUPPLIES AND SERVICES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-16
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPHA-PHR-LIC-471723336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTPHA-PHR-LIC-47172OtherSTATE OF MONTANA BOARD OF PHARMACY