MEDICARE: DEWAYNE D MONTGOMERY DPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	3944	TN

General Provider Information

NPI Number	:	1366571168
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEWAYNE D MONTGOMERY DPH

Provider Business Mailing Address
First Line	:	551 FOREST DR
Second Line	:
City	:	CROSSVILLE
State	:	TN
Zip	:	38555-8842
Country	:	US
Telephone Number	:	931-788-3499
Fax Number	:	931-484-7393

Provider Business Practice Location Address
First Line	:	1180 WEST AVE
Second Line	:
City	:	CROSSVILLE
State	:	TN
Zip	:	38555-4148
Country	:	US
Telephone Number	:	931-707-3620
Fax Number	:	931-484-7393

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/05/2007
Last Update Date	:	07/08/2007

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