Provider Demographics
NPI:1386929180
Name:MONTGOMERY, ADANA M
Entity type:Individual
Prefix:MRS
First Name:ADANA
Middle Name:M
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2909 RHODE ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34947
Mailing Address - Country:US
Mailing Address - Phone:772-489-4063
Mailing Address - Fax:561-688-2877
Practice Address - Street 1:2257 VISTA PARKWAY #14-15
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411
Practice Address - Country:US
Practice Address - Phone:561-688-2877
Practice Address - Fax:561-686-7212
Is Sole Proprietor?:No
Enumeration Date:2011-10-13
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRPT1447183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician