Provider Demographics
NPI:1093204679
Name:MELTON, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:MELTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 S RUTHERFORD BLVD
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37130-5993
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2900 S RUTHERFORD BLVD
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37130-5993
Practice Address - Country:US
Practice Address - Phone:615-896-8853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN33693183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist