Provider Demographics
NPI:1689280430
Name:COULTER, CHAD
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:COULTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601-4905
Mailing Address - Country:US
Mailing Address - Phone:406-495-6805
Mailing Address - Fax:406-495-6809
Practice Address - Street 1:2550 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-4905
Practice Address - Country:US
Practice Address - Phone:406-495-6805
Practice Address - Fax:406-495-6809
Is Sole Proprietor?:No
Enumeration Date:2020-09-17
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPHA-PHA-LIC-39441183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist