Provider Demographics
NPI:1356435762
Name:PHILL MONT COMPANY
Entity type:Organization
Organization Name:PHILL MONT COMPANY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOWERY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:712-542-6546
Mailing Address - Street 1:201 S 16TH ST
Mailing Address - Street 2:
Mailing Address - City:CLARINDA
Mailing Address - State:IA
Mailing Address - Zip Code:51632-2107
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 S 16TH ST
Practice Address - Street 2:
Practice Address - City:CLARINDA
Practice Address - State:IA
Practice Address - Zip Code:51632-2107
Practice Address - Country:US
Practice Address - Phone:712-542-6546
Practice Address - Fax:712-542-4955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA310333600000X
IA332B00000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
1614230OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MO602760605Medicaid
MO622760601Medicaid
IA0029843Medicaid
IA0029843Medicaid
1614230OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MO602760605Medicaid