Provider Demographics
NPI:1477645117
Name:WINN- DIXIE MONTGOMERY, INC.
Entity Type:Organization
Organization Name:WINN- DIXIE MONTGOMERY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MS
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:A
Authorized Official - Last Name:DOMINIQUE GOODEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-437-0541
Mailing Address - Street 1:120 RIVERLANDS DR
Mailing Address - Street 2:
Mailing Address - City:LA PLACE
Mailing Address - State:LA
Mailing Address - Zip Code:70068-7106
Mailing Address - Country:US
Mailing Address - Phone:985-651-0947
Mailing Address - Fax:
Practice Address - Street 1:3001 HIGHWAY 90 W
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:LA
Practice Address - Zip Code:70094-2758
Practice Address - Country:US
Practice Address - Phone:504-437-0541
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15427183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty