Provider Demographics
NPI:1710666219
Name:MACCALLUM, ACACIA
Entity Type:Individual
Prefix:
First Name:ACACIA
Middle Name:
Last Name:MACCALLUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ACACIA
Other - Middle Name:
Other - Last Name:LIND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:289 CHIEF LOOKING GLASS RD
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:MT
Mailing Address - Zip Code:59833-6622
Mailing Address - Country:US
Mailing Address - Phone:406-465-1894
Mailing Address - Fax:
Practice Address - Street 1:3555 MULLAN RD
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-5125
Practice Address - Country:US
Practice Address - Phone:406-251-6060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-13
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPHA-PHA-LIC-97955183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist