1578702668 NPI number — MONTGOMERY PHARMACY LLC

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 1578702668 NPI number — MONTGOMERY PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MONTGOMERY PHARMACY LLC
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:
GRANT FAMILY PHARMACY
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:
1578702668
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/20/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 388
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BENTLEY
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71407-0388
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19479 HIGHWAY 167
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BENTLEY
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71407-3502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-899-5066
Provider Business Practice Location Address Fax Number:
318-899-5069
Provider Enumeration Date:
02/12/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BARTLEY
Authorized Official First Name:
VINCE
Authorized Official Middle Name:
Authorized Official Title or Position:
R.PH/OWNER
Authorized Official Telephone Number:
318-646-6877

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PHY.006087-IR , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2118752 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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