Provider Demographics
NPI:1063010205
Name:MELLOTT, KAREN
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:MELLOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4566 S KITTREDGE ST
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80015-1442
Mailing Address - Country:US
Mailing Address - Phone:720-313-0151
Mailing Address - Fax:
Practice Address - Street 1:6603 WADSWORTH BLVD
Practice Address - Street 2:
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80003-3945
Practice Address - Country:US
Practice Address - Phone:720-313-0151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-10
Last Update Date:2020-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0023331183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist