Provider Demographics
NPI:1053547422
Name:MONTGOMERY, MELISSA KEETON (PHARMD)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:KEETON
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:MELISSA
Other - Middle Name:SUE
Other - Last Name:KEETON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:5393 DIXIE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632-6368
Mailing Address - Country:US
Mailing Address - Phone:187-788-2782
Mailing Address - Fax:901-384-9936
Practice Address - Street 1:2525 HORIZON LAKE DR STE 101
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38133-8119
Practice Address - Country:US
Practice Address - Phone:877-882-7822
Practice Address - Fax:901-384-9936
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-29
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN33539183500000X
AL14899183500000X
MS10475183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL14899OtherBOARD OF PHARMACY
MS10475OtherBOARD OF PHARMACY
TN33539OtherBOARD OF PHARMACY