Provider Demographics
NPI:1255663449
Name:MONTCALM, MARK EDWARD (PHARMD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:MONTCALM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:658 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49032-9627
Mailing Address - Country:US
Mailing Address - Phone:269-467-3510
Mailing Address - Fax:269-467-3515
Practice Address - Street 1:658 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:MI
Practice Address - Zip Code:49032-9627
Practice Address - Country:US
Practice Address - Phone:269-467-3510
Practice Address - Fax:269-467-3515
Is Sole Proprietor?:No
Enumeration Date:2010-02-12
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302035433183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist