Provider Demographics
NPI:1023105665
Name:MONTGOMERY DRUG COMPANY
Entity type:Organization
Organization Name:MONTGOMERY DRUG COMPANY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:BLEDSOE
Authorized Official - Suffix:
Authorized Official - Credentials:R PH
Authorized Official - Phone:334-358-5353
Mailing Address - Street 1:103 S MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:PRATTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36067-3621
Mailing Address - Country:US
Mailing Address - Phone:334-358-5353
Mailing Address - Fax:334-358-5352
Practice Address - Street 1:103 S MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:PRATTVILLE
Practice Address - State:AL
Practice Address - Zip Code:36067-3621
Practice Address - Country:US
Practice Address - Phone:334-358-5353
Practice Address - Fax:334-358-5352
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MONTGOMERY DRUG COMPANY, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-06
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL111580332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL100003104Medicaid
AL100003104Medicaid
AL0656260002Medicare NSC