Provider Demographics
NPI:1912091703
Name:MONTGOMERY BAPTIST OUTREACH SERVICES CORPORATION
Entity Type:Organization
Organization Name:MONTGOMERY BAPTIST OUTREACH SERVICES CORPORATION
Other - Org Name:BAPTIST TOWER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:BRUTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-273-4258
Mailing Address - Street 1:2055 E SOUTH BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36116-2001
Mailing Address - Country:US
Mailing Address - Phone:334-286-3200
Mailing Address - Fax:
Practice Address - Street 1:2055 E SOUTH BLVD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116-2001
Practice Address - Country:US
Practice Address - Phone:334-286-3200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1013173336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL100002115Medicaid
AL01 19710OtherNCPDP