Provider Demographics
NPI:1619007242
Name:PRYOR HEALTH STATION PHARMACY
Entity Type:Organization
Organization Name:PRYOR HEALTH STATION PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AREA BUSINESS OFFICE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-247-7184
Mailing Address - Street 1:PRYOR GAP RD
Mailing Address - Street 2:PO BOX 9
Mailing Address - City:PRYOR
Mailing Address - State:MT
Mailing Address - Zip Code:59066
Mailing Address - Country:US
Mailing Address - Phone:406-259-8238
Mailing Address - Fax:406-259-8290
Practice Address - Street 1:PRYOR GAP RD
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:MT
Practice Address - Zip Code:59066
Practice Address - Country:US
Practice Address - Phone:406-259-8238
Practice Address - Fax:406-259-8290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT2210000Medicaid
2763084OtherNCPDP
BU3927994OtherPHARMACY DEA