Healthcare Provider Details

I. General information

NPI: 1164104592
Provider Name (Legal Business Name): MONTGOMERY GENERAL HOSPITAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2023
Last Update Date: 08/25/2023
Certification Date: 08/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 6TH AVE
MONTGOMERY WV
25136-2116
US

IV. Provider business mailing address

PO BOX 270
MONTGOMERY WV
25136-0270
US

V. Phone/Fax

Practice location:
  • Phone: 304-442-5151
  • Fax: 304-442-7494
Mailing address:
  • Phone: 304-442-5151
  • Fax: 304-442-7494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DONNA RAYNES
Title or Position: ADMINISTRATION
Credential:
Phone: 304-442-5151