Provider Demographics
NPI:1528073152
Name:ROBERT DEAN WILCOX
Entity type:Organization
Organization Name:ROBERT DEAN WILCOX
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:WILCOX
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:406-273-2322
Mailing Address - Street 1:PO BOX 156
Mailing Address - Street 2:
Mailing Address - City:LOLO
Mailing Address - State:MT
Mailing Address - Zip Code:59847-0156
Mailing Address - Country:US
Mailing Address - Phone:406-273-2322
Mailing Address - Fax:406-273-4208
Practice Address - Street 1:103 GLACIER DR
Practice Address - Street 2:
Practice Address - City:LOLO
Practice Address - State:MT
Practice Address - Zip Code:59847-8700
Practice Address - Country:US
Practice Address - Phone:406-273-2322
Practice Address - Fax:406-273-4208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1373336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2702555OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MT6267670001Medicare NSC