Provider Demographics
NPI:1366571168
Name:MONTGOMERY, DEWAYNE D (DPH)
Entity type:Individual
Prefix:
First Name:DEWAYNE
Middle Name:D
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:551 FOREST DR
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-8842
Mailing Address - Country:US
Mailing Address - Phone:931-788-3499
Mailing Address - Fax:931-484-7393
Practice Address - Street 1:1180 WEST AVE
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-4148
Practice Address - Country:US
Practice Address - Phone:931-707-3620
Practice Address - Fax:931-484-7393
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3944183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist