MEDICARE: JENNA LYNN MONTGOMERY PHARM D

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	PSI39001	FL
2	183500000X	Pharmacist	PS64909	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PS64909	OTHER	FL	PHARMACIST LICENSE

General Provider Information

NPI Number	:	1912555822
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNA LYNN MONTGOMERY PHARM D

Provider Business Mailing Address
First Line	:	24051 PEACHLAND BLVD
Second Line	:
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33954-3714
Country	:	US
Telephone Number	:	941-627-5704
Fax Number	:

Provider Business Practice Location Address
First Line	:	24051 PEACHLAND BLVD
Second Line	:
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33954-3714
Country	:	US
Telephone Number	:	941-627-5704
Fax Number	:

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

Provider Enumeration Date	:	09/04/2019
Last Update Date	:	10/03/2022

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