Provider Demographics
NPI:1306261367
Name:MONTGOMERY, MARK (CPHT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1149 UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-8798
Mailing Address - Country:US
Mailing Address - Phone:336-584-6041
Mailing Address - Fax:
Practice Address - Street 1:1149 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-8798
Practice Address - Country:US
Practice Address - Phone:336-584-6041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-28
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician