Healthcare Provider Details

I. General information

NPI: 1093847196
Provider Name (Legal Business Name): LYCOMING COUNTY MONTGOMERY'S PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 06/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 S MAIN ST
MONTGOMERY PA
17752-1120
US

IV. Provider business mailing address

21 S MAIN ST
MONTGOMERY PA
17752-1120
US

V. Phone/Fax

Practice location:
  • Phone: 570-547-2361
  • Fax:
Mailing address:
  • Phone: 570-547-2361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPP411587L
License Number StatePA

VIII. Authorized Official

Name: PAULINE R MONTGOMERY
Title or Position: PRESIDENT
Credential: RPH
Phone: 570-584-2005