Provider Demographics
NPI:1003023565
Name:MONTAMBEAULT, LEO A JR (PHARM D)
Entity type:Individual
Prefix:DR
First Name:LEO
Middle Name:A
Last Name:MONTAMBEAULT
Suffix:JR
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6642
Mailing Address - Street 2:
Mailing Address - City:LACONIA
Mailing Address - State:NH
Mailing Address - Zip Code:03247-6642
Mailing Address - Country:US
Mailing Address - Phone:603-279-8779
Mailing Address - Fax:
Practice Address - Street 1:1839 58TH ST S
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:FL
Practice Address - Zip Code:33707-4154
Practice Address - Country:US
Practice Address - Phone:603-279-8779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS39669183500000X
MEPR4761183500000X
NHR1610183500000X
VT3451183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist