Provider Demographics
NPI:1932241700
Name:ENNIS PHARMACY AND YESTERDAY'S SODA FOUNTAIN, INC
Entity Type:Organization
Organization Name:ENNIS PHARMACY AND YESTERDAY'S SODA FOUNTAIN, INC
Other - Org Name:ENNIS HEALTH MART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY TECHNICIAN/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACY
Authorized Official - Middle Name:A
Authorized Official - Last Name:CROY
Authorized Official - Suffix:
Authorized Official - Credentials:CPT
Authorized Official - Phone:406-682-4246
Mailing Address - Street 1:PO BOX 306
Mailing Address - Street 2:124 EAST MAIN STREET
Mailing Address - City:ENNIS
Mailing Address - State:MT
Mailing Address - Zip Code:59729-0306
Mailing Address - Country:US
Mailing Address - Phone:406-682-4246
Mailing Address - Fax:406-682-7568
Practice Address - Street 1:124 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:ENNIS
Practice Address - State:MT
Practice Address - Zip Code:59729-0306
Practice Address - Country:US
Practice Address - Phone:406-682-4246
Practice Address - Fax:406-682-7568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT807183500000X
3336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT221377Medicaid