Provider Demographics
NPI:1295212918
Name:MONTGOMERY, LYDI ANN (RPH)
Entity Type:Individual
Prefix:
First Name:LYDI
Middle Name:ANN
Last Name:MONTGOMERY
Suffix:
Gender:F
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:PO BOX D
Mailing Address - Street 2:
Mailing Address - City:RIMERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16248-0504
Mailing Address - Country:US
Mailing Address - Phone:814-473-3985
Mailing Address - Fax:814-472-8228
Practice Address - Street 1:650 MAIN STREET
Practice Address - Street 2:
Practice Address - City:RIMERSBURG
Practice Address - State:PA
Practice Address - Zip Code:16248
Practice Address - Country:US
Practice Address - Phone:814-473-3985
Practice Address - Fax:814-473-8228
Is Sole Proprietor?:No
Enumeration Date:2018-07-25
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP040981L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARP040981LOtherSTATE LICENSE NUMBER