Provider Demographics
NPI:1689957771
Name:WOLDTVEDT, BRENT
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:
Last Name:WOLDTVEDT
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 1:2301 10TH AVE S
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-2967
Mailing Address - Country:US
Mailing Address - Phone:406-727-1376
Mailing Address - Fax:406-727-2964
Practice Address - Street 1:2301 10TH AVE S
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-2967
Practice Address - Country:US
Practice Address - Phone:406-727-1376
Practice Address - Fax:406-727-2964
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-24
Last Update Date:2011-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT6107183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist