Provider Demographics
NPI:1043510415
Name:MELANSON, WANDA (RPH)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:MELANSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6925 MESA RIDGE PKWY
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN
Mailing Address - State:CO
Mailing Address - Zip Code:80817-1543
Mailing Address - Country:US
Mailing Address - Phone:719-322-9357
Mailing Address - Fax:719-322-9367
Practice Address - Street 1:6925 MESA RIDGE PKWY
Practice Address - Street 2:
Practice Address - City:FOUNTAIN
Practice Address - State:CO
Practice Address - Zip Code:80817-1543
Practice Address - Country:US
Practice Address - Phone:719-322-9357
Practice Address - Fax:719-322-9367
Is Sole Proprietor?:No
Enumeration Date:2010-11-01
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO15404183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist