Basic Information
| Provider Information | |||||||||
| NPI: | 1093067449 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIDEBOTTOM | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RPH | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SLAGLE | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RPH | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | P.O. BOX 880 | ||||||||
| Address2: | |||||||||
| City: | ST IGNATIUS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 59865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067453525 | ||||||||
| FaxNumber: | 4068833512 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 4TH AVE. EAST | ||||||||
| Address2: | |||||||||
| City: | POLSON | ||||||||
| State: | MT | ||||||||
| PostalCode: | 59860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4068835541 | ||||||||
| FaxNumber: | 4068833512 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2012 | ||||||||
| LastUpdateDate: | 10/10/2012 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 7915 | MT | Y | Pharmacy Service Providers | Pharmacist | 183500000X | 43052 | CA | N | Pharmacy Service Providers | Pharmacist |
No ID Information.