Provider Demographics
NPI:1063015030
Name:MELNYCHUK, KELLY (RPH)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MELNYCHUK
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 1:72 BOARDMAN AVE
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:RI
Mailing Address - Zip Code:02864-3722
Mailing Address - Country:US
Mailing Address - Phone:401-212-7026
Mailing Address - Fax:
Practice Address - Street 1:120 EDDIE DOWLING HWY
Practice Address - Street 2:
Practice Address - City:NORTH SMITHFIELD
Practice Address - State:RI
Practice Address - Zip Code:02896-8214
Practice Address - Country:US
Practice Address - Phone:401-762-3172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI3730183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist