Provider Demographics
NPI:1669501649
Name:LODGE GRASS HEALTH CENTER PHARMACY
Entity Type:Organization
Organization Name:LODGE GRASS HEALTH CENTER 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:HARDING AVE
Mailing Address - Street 2:PO BOX 780
Mailing Address - City:LODGE GRASS
Mailing Address - State:MT
Mailing Address - Zip Code:59050
Mailing Address - Country:US
Mailing Address - Phone:406-639-2317
Mailing Address - Fax:406-639-2976
Practice Address - Street 1:HARDING AVE
Practice Address - Street 2:
Practice Address - City:LODGE GRASS
Practice Address - State:MT
Practice Address - Zip Code:59050
Practice Address - Country:US
Practice Address - Phone:406-639-2317
Practice Address - Fax:406-639-2976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
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
2762955OtherNCPDP NUMBER
MT2210085Medicaid
BU4083779OtherPHARMACY DEA NUMBER