Provider Demographics
NPI:1770952137
Name:MONTGOMERY, ROBERT A
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4752 SR 655
Mailing Address - Street 2:SUITE A
Mailing Address - City:BELLEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17004
Mailing Address - Country:US
Mailing Address - Phone:717-935-2341
Mailing Address - Fax:717-935-5465
Practice Address - Street 1:4752 SR 655
Practice Address - Street 2:SUITE A
Practice Address - City:BELLEVILLE
Practice Address - State:PA
Practice Address - Zip Code:17004
Practice Address - Country:US
Practice Address - Phone:717-935-2341
Practice Address - Fax:717-935-5465
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP432924R183500000X
VA0202012515183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist