Provider Demographics
NPI:1215106703
Name:POULTON, CORY THOMAS
Entity type:Individual
Prefix:MR
First Name:CORY
Middle Name:THOMAS
Last Name:POULTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 5TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:CUT BANK
Mailing Address - State:MT
Mailing Address - Zip Code:59427
Mailing Address - Country:US
Mailing Address - Phone:406-873-2127
Mailing Address - Fax:406-873-3250
Practice Address - Street 1:760 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:BROWNING
Practice Address - State:MT
Practice Address - Zip Code:59417
Practice Address - Country:US
Practice Address - Phone:406-338-8908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-28
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT3961183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist