Provider Demographics
NPI:1912555822
Name:MONTGOMERY, JENNA LYNN (PHARM D)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:LYNN
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24051 PEACHLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33954-3714
Mailing Address - Country:US
Mailing Address - Phone:941-627-5704
Mailing Address - Fax:
Practice Address - Street 1:24051 PEACHLAND BLVD
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33954-3714
Practice Address - Country:US
Practice Address - Phone:941-627-5704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-04
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPSI39001183500000X
FLPS64909183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS64909OtherPHARMACIST LICENSE