Provider Demographics
NPI:1942394424
Name:GILLETTE PHARMACY, INC.
Entity Type:Organization
Organization Name:GILLETTE PHARMACY, INC.
Other - Org Name:GILLETTE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:MAXSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-653-2850
Mailing Address - Street 1:228 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WOLF POINT
Mailing Address - State:MT
Mailing Address - Zip Code:59201
Mailing Address - Country:US
Mailing Address - Phone:406-653-2850
Mailing Address - Fax:
Practice Address - Street 1:228 MAIN STREET
Practice Address - Street 2:
Practice Address - City:WOLF POINT
Practice Address - State:MT
Practice Address - Zip Code:59201
Practice Address - Country:US
Practice Address - Phone:406-653-2850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT4773336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000219284Medicaid