Provider Demographics
NPI:1255998928
Name:MONTGOMERY, JAYSON ALLAN
Entity type:Individual
Prefix:
First Name:JAYSON
Middle Name:ALLAN
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4903 ENGLE FOREST CIR
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77346-4413
Mailing Address - Country:US
Mailing Address - Phone:281-229-4521
Mailing Address - Fax:
Practice Address - Street 1:1408 N 16TH ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:TX
Practice Address - Zip Code:77630-3612
Practice Address - Country:US
Practice Address - Phone:409-883-0876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63307183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist