1528073152 NPI number — ROBERT DEAN WILCOX

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528073152 NPI number — ROBERT DEAN WILCOX

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROBERT DEAN WILCOX
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LOLO DRUG
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528073152
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/23/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 156
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOLO
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59847-0156
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-273-2322
Provider Business Mailing Address Fax Number:
406-273-4208

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
103 GLACIER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOLO
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59847-8700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-273-2322
Provider Business Practice Location Address Fax Number:
406-273-4208
Provider Enumeration Date:
07/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILCOX
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
DEAN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
406-273-2322

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  137 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2702555 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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