Provider Demographics
NPI:1679977433
Name:SUPERIOR SPECIALTY PHARMACY OF MONTANA, LLC
Entity type:Organization
Organization Name:SUPERIOR SPECIALTY PHARMACY OF MONTANA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:GRADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-752-0440
Mailing Address - Street 1:1600 WHITEFISH STAGE ROAD
Mailing Address - Street 2:SUITE #2
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901
Mailing Address - Country:US
Mailing Address - Phone:406-752-0499
Mailing Address - Fax:406-752-0498
Practice Address - Street 1:20 FOUR MILE DR STE 4
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-2644
Practice Address - Country:US
Practice Address - Phone:406-752-0499
Practice Address - Fax:406-752-0498
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUPERIOR SPECIALTY PHARMACY OF MONTANA, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-10-22
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT12093336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2148091OtherPK