Provider Demographics
NPI:1396391900
Name:CHINIKAYLO, ROMAN MIKHAYLOVICH (PHARMD)
Entity Type:Individual
Prefix:
First Name:ROMAN
Middle Name:MIKHAYLOVICH
Last Name:CHINIKAYLO
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8625 MOURNING DOVE DR
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-1024
Mailing Address - Country:US
Mailing Address - Phone:406-239-2757
Mailing Address - Fax:
Practice Address - Street 1:1003 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4971
Practice Address - Country:US
Practice Address - Phone:406-549-6163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-11
Last Update Date:2019-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPHA-PHA-LIC-62920183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTPHA-PHA-LIC-62920OtherSTATE OF MONTANA