MEDICARE: MR. DWIGHT RANDOLPH MONTFORT RPH.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	28RI02451100	NJ

General Provider Information

NPI Number	:	1144537101
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DWIGHT RANDOLPH MONTFORT RPH.

Provider Business Mailing Address
First Line	:	179 BENNETT AVE
Second Line	:	APT 8G
City	:	NEW YORK
State	:	NY
Zip	:	10040-4036
Country	:	US
Telephone Number	:	646-296-8749
Fax Number	:

Provider Business Practice Location Address
First Line	:	5313 HUDSON AVE
Second Line	:
City	:	WEST NEW YORK
State	:	NJ
Zip	:	07093
Country	:	US
Telephone Number	:	646-296-8749
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/10/2010
Last Update Date	:	09/10/2010

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