Provider Demographics
NPI:1578702668
Name:MONTGOMERY PHARMACY LLC
Entity Type:Organization
Organization Name:MONTGOMERY PHARMACY LLC
Other - Org Name:GRANT FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:R.PH/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VINCE
Authorized Official - Middle Name:
Authorized Official - Last Name:BARTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-646-6877
Mailing Address - Street 1:PO BOX 388
Mailing Address - Street 2:
Mailing Address - City:BENTLEY
Mailing Address - State:LA
Mailing Address - Zip Code:71407-0388
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19479 HIGHWAY 167
Practice Address - Street 2:
Practice Address - City:BENTLEY
Practice Address - State:LA
Practice Address - Zip Code:71407-3502
Practice Address - Country:US
Practice Address - Phone:318-899-5066
Practice Address - Fax:318-899-5069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-12
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
LAPHY.006087-IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2118752OtherPK
LA5005730002Medicare NSC