Provider Demographics
NPI:1609197664
Name:MONFORT DRUG AND COMPOUNDING COMPANY INC
Entity Type:Organization
Organization Name:MONFORT DRUG AND COMPOUNDING COMPANY INC
Other - Org Name:MONFORT DRUG AND COMPOUNDING COMPANY, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-963-2438
Mailing Address - Street 1:470 N CLAYTON ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-4872
Mailing Address - Country:US
Mailing Address - Phone:770-963-2438
Mailing Address - Fax:770-963-0166
Practice Address - Street 1:470 N CLAYTON ST STE 101
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4872
Practice Address - Country:US
Practice Address - Phone:770-963-2438
Practice Address - Fax:770-963-0166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-14
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
GAPHRE0055293336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1159981OtherNCPDP PROVIDER IDENTIFICATION NUMBER