Basic Information
| Provider Information | |||||||||
| NPI: | 1144883984 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BUTTE SILVER BOW PRIMARY HEALTH CARE CLINIC INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BLACKTAIL PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 445 CENTENNIAL AVE | ||||||||
| Address2: | |||||||||
| City: | BUTTE | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597012870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4064966000 | ||||||||
| FaxNumber: | 4064966035 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 E GLENDALE ST | ||||||||
| Address2: | |||||||||
| City: | DILLON | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597252505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4069880772 | ||||||||
| FaxNumber: | 4069880774 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2019 | ||||||||
| LastUpdateDate: | 06/10/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COX | ||||||||
| AuthorizedOfficialFirstName: | TAMMY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACY DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4064966033 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BUTTE SILVER BOW PRIMARY HEALTH CARE CLINIC INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHARMD | ||||||||
| NPICertificationDate: | 06/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
No ID Information.