Provider Demographics
NPI:1871695213
Name:MINERAL PHARMACY INC
Entity type:Organization
Organization Name:MINERAL PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/VP
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-822-4681
Mailing Address - Street 1:207 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:MT
Mailing Address - Zip Code:59872-9673
Mailing Address - Country:US
Mailing Address - Phone:406-822-4681
Mailing Address - Fax:406-822-0057
Practice Address - Street 1:207 RIVER ST
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:MT
Practice Address - Zip Code:59872-9673
Practice Address - Country:US
Practice Address - Phone:406-822-4681
Practice Address - Fax:406-822-0057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MT499353336C0003X
MT7023336C0003X
MTPHA-PHR-LIC-49935333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1871695213Medicaid
2050377OtherPK