Provider Demographics
NPI:1912940297
Name:KOOTENAI DRUG AND HARDWARE INC
Entity Type:Organization
Organization Name:KOOTENAI DRUG AND HARDWARE INC
Other - Org Name:KOOTENAI DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:HERMES
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:406-295-4361
Mailing Address - Street 1:611 E MISSOULA AVE
Mailing Address - Street 2:PO BOX 328
Mailing Address - City:TROY
Mailing Address - State:MT
Mailing Address - Zip Code:59935
Mailing Address - Country:US
Mailing Address - Phone:406-295-4361
Mailing Address - Fax:406-295-5326
Practice Address - Street 1:611 E MISSOULA AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MT
Practice Address - Zip Code:59935
Practice Address - Country:US
Practice Address - Phone:406-295-4361
Practice Address - Fax:406-295-5326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MT11503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2050152OtherPK
MT0214455Medicaid
5576970001Medicare NSC