Provider Demographics
NPI:1568700938
Name:MONTENEGRO, AIDA J
Entity Type:Individual
Prefix:
First Name:AIDA
Middle Name:J
Last Name:MONTENEGRO
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 1:15801 SHERIDAN ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33331-3487
Mailing Address - Country:US
Mailing Address - Phone:954-442-6875
Mailing Address - Fax:954-442-5061
Practice Address - Street 1:15801 SHERIDAN ST
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33331-3487
Practice Address - Country:US
Practice Address - Phone:954-442-6875
Practice Address - Fax:954-442-5061
Is Sole Proprietor?:No
Enumeration Date:2013-01-19
Last Update Date:2013-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS21352183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist