Provider Demographics
NPI:1619523792
Name:GANTZ, MICHAEL R (PHARMD, RPH)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:GANTZ
Suffix:
Gender:M
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3687 VETERANS DR
Mailing Address - Street 2:
Mailing Address - City:FORT HARRISON
Mailing Address - State:MT
Mailing Address - Zip Code:59636-9700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3687 VETERANS DR
Practice Address - Street 2:
Practice Address - City:FORT HARRISON
Practice Address - State:MT
Practice Address - Zip Code:59636-9700
Practice Address - Country:US
Practice Address - Phone:406-442-6410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-14
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPHA-PHA-LIC-55047183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist