Provider Demographics
NPI:1407455454
Name:ERICKSON, SHIRLEY A (RPH)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:A
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1030
Mailing Address - Street 2:
Mailing Address - City:RED LODGE
Mailing Address - State:MT
Mailing Address - Zip Code:59068-1030
Mailing Address - Country:US
Mailing Address - Phone:406-446-1017
Mailing Address - Fax:406-446-2516
Practice Address - Street 1:211 N BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:RED LODGE
Practice Address - State:MT
Practice Address - Zip Code:59068
Practice Address - Country:US
Practice Address - Phone:406-446-1017
Practice Address - Fax:406-446-2516
Is Sole Proprietor?:No
Enumeration Date:2020-10-21
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT3411183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist