Provider Demographics
NPI:1477069193
Name:406 RX PLLC
Entity Type:Organization
Organization Name:406 RX PLLC
Other - Org Name:THREE FORKS FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSH
Authorized Official - Middle Name:
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-207-8043
Mailing Address - Street 1:PO BOX 1469
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MT
Mailing Address - Zip Code:59019-1469
Mailing Address - Country:US
Mailing Address - Phone:406-207-8043
Mailing Address - Fax:406-285-3877
Practice Address - Street 1:117 N MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:THREE FORKS
Practice Address - State:MT
Practice Address - Zip Code:59752-9013
Practice Address - Country:US
Practice Address - Phone:406-285-3883
Practice Address - Fax:406-285-3877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-18
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1477069193Medicaid