Provider Demographics
NPI:1336699537
Name:MONTGOMERY, MATT (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MATT
Middle Name:
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 1:4103 CEDAR CIRCLE MSC 1500
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33620-5760
Mailing Address - Country:US
Mailing Address - Phone:813-974-1206
Mailing Address - Fax:813-974-4383
Practice Address - Street 1:4103 CEDAR CIRCLE MSC 1500
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33620-5760
Practice Address - Country:US
Practice Address - Phone:813-974-1206
Practice Address - Fax:813-974-4383
Is Sole Proprietor?:No
Enumeration Date:2016-10-11
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS55349183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist