Provider Demographics
NPI:1104430867
Name:MONTGOMERY, MATTHEW SCOTT (PHARMD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:SCOTT
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4429 APPLE LEAF DR E
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-8614
Mailing Address - Country:US
Mailing Address - Phone:904-570-2369
Mailing Address - Fax:
Practice Address - Street 1:10899 BAYMEADOWS RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-4603
Practice Address - Country:US
Practice Address - Phone:904-519-6277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS0036892183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS0036892OtherFL PHARMACIST LICENSE