Provider Demographics
NPI:1134714652
Name:MONTAGUE, SAMANTHA (CPHT)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:MONTAGUE
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3871 CHRIVIA RD
Mailing Address - Street 2:
Mailing Address - City:LUPTON
Mailing Address - State:MI
Mailing Address - Zip Code:48635-8748
Mailing Address - Country:US
Mailing Address - Phone:989-709-8046
Mailing Address - Fax:
Practice Address - Street 1:3871 CHRIVIA RD
Practice Address - Street 2:
Practice Address - City:LUPTON
Practice Address - State:MI
Practice Address - Zip Code:48635-8748
Practice Address - Country:US
Practice Address - Phone:989-709-8046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303000390183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician