Provider Demographics
NPI:1831296672
Name:MONTGOMERY CANCER CENTER LLC
Entity Type:Organization
Organization Name:MONTGOMERY CANCER CENTER LLC
Other - Org Name:MCC APOTHECARY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR OF PHCY
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:334-273-2252
Mailing Address - Street 1:4145 CARMICHAEL RD
Mailing Address - Street 2:STE A
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-2803
Mailing Address - Country:US
Mailing Address - Phone:334-273-2281
Mailing Address - Fax:334-368-2936
Practice Address - Street 1:4145 CARMICHAEL RD
Practice Address - Street 2:STE A
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-2803
Practice Address - Country:US
Practice Address - Phone:334-273-2281
Practice Address - Fax:334-386-2936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
AL1117633336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0130219OtherNCPDP PROVIDER IDENTIFICATION NUMBER
4248810001Medicare NSC