Provider Demographics
NPI:1376265355
Name:MONTGOMERY, JAMESINA WATSON
Entity Type:Individual
Prefix:
First Name:JAMESINA
Middle Name:WATSON
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 1:3700 BRADFORDVILLE RD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32309-1960
Mailing Address - Country:US
Mailing Address - Phone:850-894-3249
Mailing Address - Fax:
Practice Address - Street 1:3700 BRADFORDVILLE RD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32309-1960
Practice Address - Country:US
Practice Address - Phone:850-894-3249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-15
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS30813183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist