Provider Demographics
NPI:1467406389
Name:BENTON PHARMACY INC
Entity Type:Organization
Organization Name:BENTON PHARMACY INC
Other - Org Name:BENTON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RPH,OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:HALKO
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:406-622-5588
Mailing Address - Street 1:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:FORT BENTON
Mailing Address - State:MT
Mailing Address - Zip Code:59442-0549
Mailing Address - Country:US
Mailing Address - Phone:406-622-5588
Mailing Address - Fax:406-622-5088
Practice Address - Street 1:1418 FRONT ST
Practice Address - Street 2:
Practice Address - City:FORT BENTON
Practice Address - State:MT
Practice Address - Zip Code:59442-8884
Practice Address - Country:US
Practice Address - Phone:406-622-5588
Practice Address - Fax:406-622-5088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
MT11513336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1467406389Medicaid
2049905OtherPK
MT216567Medicaid
MT216567Medicaid