Provider Demographics
NPI:1649679598
Name:FOUNTAINE, BRETT (RPH)
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:
Last Name:FOUNTAINE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3255 TECHNOLOGY BLVD W
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-6854
Mailing Address - Country:US
Mailing Address - Phone:406-587-4005
Mailing Address - Fax:
Practice Address - Street 1:3255 TECHNOLOGY BLVD W
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-6854
Practice Address - Country:US
Practice Address - Phone:406-587-4005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-16
Last Update Date:2014-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2987183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist