Basic Information
| Provider Information | |||||||||
| NPI: | 1194350033 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICKEY | ||||||||
| FirstName: | MONTANA | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PHARM. D | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 101 BODIN CIR | ||||||||
| Address2: | |||||||||
| City: | TRAVIS AFB | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945351809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074237384 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 101 BODIN CIR | ||||||||
| Address2: | |||||||||
| City: | TRAVIS AFB | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945351809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074233000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2020 | ||||||||
| LastUpdateDate: | 11/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | I-9661 | OK | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.