Provider Demographics
NPI:1679004436
Name:MONTGOMERY AIDS OUTREACH INC
Entity type:Organization
Organization Name:MONTGOMERY AIDS OUTREACH INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER (COO)
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:TARRANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-280-3349
Mailing Address - Street 1:PO BOX 11087
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36111-0087
Mailing Address - Country:US
Mailing Address - Phone:334-280-3349
Mailing Address - Fax:334-281-2308
Practice Address - Street 1:2900 MCGEHEE RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36111-2151
Practice Address - Country:US
Practice Address - Phone:334-239-9692
Practice Address - Fax:334-356-2529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-23
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
AL1147053336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2168269OtherPK
AL197966Medicaid