Provider Demographics
NPI:1659504363
Name:GLACIER RIDGE PHARMACY INC
Entity Type:Organization
Organization Name:GLACIER RIDGE PHARMACY INC
Other - Org Name:ALPINE RIDGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKONSKI-LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:406-370-9877
Mailing Address - Street 1:6475 US HIGHWAY 93 S
Mailing Address - Street 2:
Mailing Address - City:WHITEFISH
Mailing Address - State:MT
Mailing Address - Zip Code:59937-8282
Mailing Address - Country:US
Mailing Address - Phone:406-862-7434
Mailing Address - Fax:406-862-7432
Practice Address - Street 1:6475 US HIGHWAY 93 S
Practice Address - Street 2:
Practice Address - City:WHITEFISH
Practice Address - State:MT
Practice Address - Zip Code:59937-8282
Practice Address - Country:US
Practice Address - Phone:406-862-7434
Practice Address - Fax:406-862-7432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-27
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X
MT12953336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1659504363Medicaid
2783567OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MT1659504363Medicaid