Provider Demographics
NPI:1518007731
Name:LEE & DADS GROCERY INC
Entity Type:Organization
Organization Name:LEE & DADS GROCERY INC
Other - Org Name:TOWN AND COUNTRY FOODS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST-IN-CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:BROOKE
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:406-388-4111
Mailing Address - Street 1:205 W MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:BELGRADE
Mailing Address - State:MT
Mailing Address - Zip Code:59714-3906
Mailing Address - Country:US
Mailing Address - Phone:406-388-4111
Mailing Address - Fax:406-388-4113
Practice Address - Street 1:205 W MADISON AVE
Practice Address - Street 2:
Practice Address - City:BELGRADE
Practice Address - State:MT
Practice Address - Zip Code:59714-3906
Practice Address - Country:US
Practice Address - Phone:406-388-4111
Practice Address - Fax:406-388-4113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0220082Medicaid
MT871OtherLICENSE NUMBER