MEDICARE: AIDA J MONTENEGRO

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	PS21352	FL

General Provider Information

NPI Number	:	1568700938
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AIDA J MONTENEGRO

Provider Business Mailing Address
First Line	:	15801 SHERIDAN ST
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33331-3487
Country	:	US
Telephone Number	:	954-442-6875
Fax Number	:	954-442-5061

Provider Business Practice Location Address
First Line	:	15801 SHERIDAN ST
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33331-3487
Country	:	US
Telephone Number	:	954-442-6875
Fax Number	:	954-442-5061

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

Provider Enumeration Date	:	01/19/2013
Last Update Date	:	01/19/2013

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