Healthcare Provider Details

I. General information

NPI: 1003590860
Provider Name (Legal Business Name): MONTANA ZITNAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 06/12/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2825 N KANSAS EXPY
SPRINGFIELD MO
65803-1017
US

IV. Provider business mailing address

634 E WALNUT LAWN ST APT C102
SPRINGFIELD MO
65807-5083
US

V. Phone/Fax

Practice location:
  • Phone: 417-831-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2022032173
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: