Basic Information
| Provider Information | |||||||||
| NPI: | 1942744594 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FARAGO | ||||||||
| FirstName: | KRISTY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2750 PROSPECT AVE | ||||||||
| Address2: | |||||||||
| City: | HELENA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 596019741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4064433455 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2750 PROSPECT AVE | ||||||||
| Address2: | |||||||||
| City: | HELENA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 596019741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4064433455 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2016 | ||||||||
| LastUpdateDate: | 12/15/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 3025 | MT | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 3025 | 01 | MT | PHARMACY LIC | OTHER |