Healthcare Provider Details

I. General information

NPI: 1225645708
Provider Name (Legal Business Name): DYLAN S MONTGOMERY PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2020
Last Update Date: 09/28/2020
Certification Date: 09/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3131 S HOOVER ST
LOS ANGELES CA
90089-3527
US

IV. Provider business mailing address

3637 CLARINGTON AVE APT 110
LOS ANGELES CA
90034-5099
US

V. Phone/Fax

Practice location:
  • Phone: 213-763-0588
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number83113
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: