Provider Demographics
NPI:1831512342
Name:MINING CITY COMPOUNDING PHARMACY LLC
Entity type:Organization
Organization Name:MINING CITY COMPOUNDING PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:OCONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-723-3308
Mailing Address - Street 1:327 S EXCELSIOR AVE
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-1536
Mailing Address - Country:US
Mailing Address - Phone:406-723-3308
Mailing Address - Fax:406-782-8243
Practice Address - Street 1:327 S EXCELSIOR AVE
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-1536
Practice Address - Country:US
Practice Address - Phone:406-723-3308
Practice Address - Fax:406-782-8243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-04
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MT214763336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2144257OtherPK