Provider Demographics
NPI:1639129497
Name:HAINES MEDICAL PHARMACY, INC.
Entity Type:Organization
Organization Name:HAINES MEDICAL PHARMACY, INC.
Other - Org Name:HAINES MEDICAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACY MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:S
Authorized Official - Last Name:MACKENZIE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:406-862-6301
Mailing Address - Street 1:1111 BAKER AVE
Mailing Address - Street 2:
Mailing Address - City:WHITEFISH
Mailing Address - State:MT
Mailing Address - Zip Code:59937-2905
Mailing Address - Country:US
Mailing Address - Phone:406-862-6301
Mailing Address - Fax:406-862-6312
Practice Address - Street 1:1111 BAKER AVE
Practice Address - Street 2:
Practice Address - City:WHITEFISH
Practice Address - State:MT
Practice Address - Zip Code:59937-2905
Practice Address - Country:US
Practice Address - Phone:406-862-6301
Practice Address - Fax:406-862-6312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10643336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1064OtherMT PHARMACY #
MT2706565OtherNABP #
MT212772Medicaid
MT212772Medicaid