Provider Demographics
NPI:1740370667
Name:MONTROSS PHARMACY INC
Entity type:Organization
Organization Name:MONTROSS PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-462-2282
Mailing Address - Street 1:134 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:IA
Mailing Address - Zip Code:50240-7701
Mailing Address - Country:US
Mailing Address - Phone:641-396-2445
Mailing Address - Fax:641-396-2830
Practice Address - Street 1:134 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:IA
Practice Address - Zip Code:50240-7701
Practice Address - Country:US
Practice Address - Phone:641-396-2445
Practice Address - Fax:641-396-2830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IA1113336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2026849OtherPK
IA014671Medicaid