Basic Information
Provider Information | |||||||||
NPI: | 1053547422 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MONTGOMERY | ||||||||
FirstName: | MELISSA | ||||||||
MiddleName: | KEETON | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHARM.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KEETON | ||||||||
OtherFirstName: | MELISSA | ||||||||
OtherMiddleName: | SUE | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PHARM.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 5393 DIXIE CREEK DR | ||||||||
Address2: |   | ||||||||
City: | HERNANDO | ||||||||
State: | MS | ||||||||
PostalCode: | 386326368 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 1877882782 | ||||||||
FaxNumber: | 9013849936 | ||||||||
Practice Location | |||||||||
Address1: | 2525 HORIZON LAKE DR STE 101 | ||||||||
Address2: |   | ||||||||
City: | MEMPHIS | ||||||||
State: | TN | ||||||||
PostalCode: | 381338119 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8778827822 | ||||||||
FaxNumber: | 9013849936 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/29/2009 | ||||||||
LastUpdateDate: | 05/29/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 33539 | TN | Y |   | Pharmacy Service Providers | Pharmacist |   | 183500000X | 14899 | AL | N |   | Pharmacy Service Providers | Pharmacist |   | 183500000X | 10475 | MS | N |   | Pharmacy Service Providers | Pharmacist |   |
ID Information
ID | Type | State | Issuer | Description | 14899 | 01 | AL | BOARD OF PHARMACY | OTHER | 10475 | 01 | MS | BOARD OF PHARMACY | OTHER | 33539 | 01 | TN | BOARD OF PHARMACY | OTHER |