Provider Demographics
NPI:1073628095
Name:MELROSE PHARMACY LLC
Entity Type:Organization
Organization Name:MELROSE PHARMACY LLC
Other - Org Name:MELROSE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:STICKLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-277-4714
Mailing Address - Street 1:706 W MONTECITO AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-2814
Mailing Address - Country:US
Mailing Address - Phone:602-277-4714
Mailing Address - Fax:602-264-1469
Practice Address - Street 1:706 W MONTECITO AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-2814
Practice Address - Country:US
Practice Address - Phone:602-277-4714
Practice Address - Fax:602-264-1469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336S0011X
AZY042793336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ980319Medicaid
1991935OtherPK
5608730001Medicare NSC