Healthcare Provider Details

I. General information

NPI: 1255836037
Provider Name (Legal Business Name): CLARICE MONTGOMERY PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2018
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 N COLLEGE AVE
FAYETTEVILLE AR
72703-1944
US

IV. Provider business mailing address

PO BOX 2429
SMYRNA TN
37167-1719
US

V. Phone/Fax

Practice location:
  • Phone: 479-443-4301
  • Fax:
Mailing address:
  • Phone: 615-355-3451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License NumberPD14202
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: