Provider Demographics
NPI:1760576714
Name:SUPERIOR SPECIALTY PHARMACY OF MONTANA, LLC
Entity Type:Organization
Organization Name:SUPERIOR SPECIALTY PHARMACY OF MONTANA, LLC
Other - Org Name:BIG SKY IV CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:GRADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-752-0440
Mailing Address - Street 1:560 CASCADE LOOP
Mailing Address - Street 2:SUITE 1
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901
Mailing Address - Country:US
Mailing Address - Phone:406-752-0440
Mailing Address - Fax:406-752-0443
Practice Address - Street 1:560 CASCADE LOOP
Practice Address - Street 2:SUITE 1
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901
Practice Address - Country:US
Practice Address - Phone:406-752-0440
Practice Address - Fax:406-752-0443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10706163WI0500X, 251F00000X
MT1144332BP3500X, 333600000X, 3336H0001X, 3336L0003X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy PharmacyGroup - Single Specialty
No163WI0500XNursing Service ProvidersRegistered NurseInfusion TherapyGroup - Single Specialty
No251F00000XAgenciesHome Infusion
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral NutritionGroup - Single Specialty
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0562530Medicaid
MT308210OtherBLUE CROSS/SHIELD MT
MT0380528Medicaid
MT0562547Medicaid
MT5546250001Medicare NSC