Provider Demographics
NPI:1881921005
Name:MONTGOMERY, VANESSA JEAN (PHARMD)
Entity type:Individual
Prefix:DR
First Name:VANESSA
Middle Name:JEAN
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6310 SOUTHWEST BLVD STE 204
Mailing Address - Street 2:
Mailing Address - City:BENBROOK
Mailing Address - State:TX
Mailing Address - Zip Code:76109-6916
Mailing Address - Country:US
Mailing Address - Phone:866-869-7307
Mailing Address - Fax:
Practice Address - Street 1:6048 S HULEN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-2604
Practice Address - Country:US
Practice Address - Phone:817-423-5326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-09
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45264183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist