Provider Demographics
NPI:1750439709
Name:MATOVICH ENTERPRISES INC
Entity type:Organization
Organization Name:MATOVICH ENTERPRISES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MATOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:406-322-5652
Mailing Address - Street 1:PO BOX 719
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MT
Mailing Address - Zip Code:59019-0719
Mailing Address - Country:US
Mailing Address - Phone:406-322-5652
Mailing Address - Fax:406-322-4960
Practice Address - Street 1:133 N 5TH
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MT
Practice Address - Zip Code:59019
Practice Address - Country:US
Practice Address - Phone:406-322-5652
Practice Address - Fax:406-322-4960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336L0003X
MTPHA-PHR-LIC-6023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2050295OtherPK
MT212194Medicaid
MT0235360Medicaid
2050295OtherPK