Provider Demographics
NPI:1073896627
Name:BAILEY, MONTY RAY (RPH)
Entity Type:Individual
Prefix:MR
First Name:MONTY
Middle Name:RAY
Last Name:BAILEY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67211-3131
Mailing Address - Country:US
Mailing Address - Phone:316-262-5383
Mailing Address - Fax:316-262-7469
Practice Address - Street 1:1555 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67211-3131
Practice Address - Country:US
Practice Address - Phone:316-262-5383
Practice Address - Fax:316-262-7469
Is Sole Proprietor?:No
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-12395183500000X
OK9490183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist