Provider Demographics
NPI:1942358940
Name:LYCOMING COUNTY MONTGOMERYS
Entity Type:Organization
Organization Name:LYCOMING COUNTY MONTGOMERYS
Other - Org Name:MONTGOMERYS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-584-2005
Mailing Address - Street 1:49 N RAILROAD ST
Mailing Address - Street 2:
Mailing Address - City:HUGHESVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17737-1213
Mailing Address - Country:US
Mailing Address - Phone:570-584-2005
Mailing Address - Fax:570-584-5115
Practice Address - Street 1:49 N RAILROAD ST
Practice Address - Street 2:
Practice Address - City:HUGHESVILLE
Practice Address - State:PA
Practice Address - Zip Code:17737-1213
Practice Address - Country:US
Practice Address - Phone:570-584-2005
Practice Address - Fax:570-584-5115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP411615L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100776565Medicaid
2079796OtherPK
PA884111Medicaid
PA884111Medicaid