Provider Demographics
NPI:1922176940
Name:MONTANA COMPOUNDING PHARMACY
Entity Type:Organization
Organization Name:MONTANA COMPOUNDING PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:G
Authorized Official - Last Name:CALCAGNO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:406-542-2888
Mailing Address - Street 1:111 N HIGGINS AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-4494
Mailing Address - Country:US
Mailing Address - Phone:406-542-2888
Mailing Address - Fax:
Practice Address - Street 1:111 N HIGGINS AVE STE 5
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4494
Practice Address - Country:US
Practice Address - Phone:406-542-2888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT892183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000211616Medicaid