Provider Demographics
NPI:1285791590
Name:KCS WESTERN DRUG INC
Entity type:Organization
Organization Name:KCS WESTERN DRUG INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KARI
Authorized Official - Middle Name:
Authorized Official - Last Name:VONDRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-222-7332
Mailing Address - Street 1:PO BOX 67
Mailing Address - Street 2:
Mailing Address - City:GARDINER
Mailing Address - State:MT
Mailing Address - Zip Code:59030-0067
Mailing Address - Country:US
Mailing Address - Phone:406-848-9430
Mailing Address - Fax:406-848-9465
Practice Address - Street 1:318 PARK ST
Practice Address - Street 2:
Practice Address - City:GARDINER
Practice Address - State:MT
Practice Address - Zip Code:59030-7735
Practice Address - Country:US
Practice Address - Phone:406-848-9430
Practice Address - Fax:406-848-9465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MTPHA-PHR-LIC-279613336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1235534561Medicaid
MT1235534561Medicaid