Provider Demographics
NPI:1104923945
Name:MONTGOMERY DRUG COMPANY INC
Entity type:Organization
Organization Name:MONTGOMERY DRUG COMPANY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:PHUNG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:334-272-0802
Mailing Address - Street 1:35 MITCHELL DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36109-2923
Mailing Address - Country:US
Mailing Address - Phone:334-272-0802
Mailing Address - Fax:334-272-0882
Practice Address - Street 1:35 MITCHELL DR
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36109-2923
Practice Address - Country:US
Practice Address - Phone:334-272-0802
Practice Address - Fax:334-272-0882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AL1010163336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL100002564Medicaid
1991395OtherPK