Provider Demographics
NPI:1598770109
Name:MONTGOMERY DRUG CO INC
Entity Type:Organization
Organization Name:MONTGOMERY DRUG CO INC
Other - Org Name:MONTGOMERY DRUG COMPANY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COOWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDLE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:662-489-5555
Mailing Address - Street 1:349 HIGHWAY 15 N
Mailing Address - Street 2:
Mailing Address - City:PONTOTOC
Mailing Address - State:MS
Mailing Address - Zip Code:38863-1105
Mailing Address - Country:US
Mailing Address - Phone:662-489-5555
Mailing Address - Fax:662-489-6759
Practice Address - Street 1:349 HIGHWAY 15 N
Practice Address - Street 2:
Practice Address - City:PONTOTOC
Practice Address - State:MS
Practice Address - Zip Code:38863-1105
Practice Address - Country:US
Practice Address - Phone:662-489-5555
Practice Address - Fax:662-489-6759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
MS01025/1.13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00093700Medicaid
2044591OtherPK