Provider Demographics
NPI:1114108206
Name:MELISI, ANDREW LAWRENCE (RPH)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:LAWRENCE
Last Name:MELISI
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 GRAND ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10002-4702
Mailing Address - Country:US
Mailing Address - Phone:212-529-7115
Mailing Address - Fax:212-598-5961
Practice Address - Street 1:408 GRAND ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-4702
Practice Address - Country:US
Practice Address - Phone:212-529-7115
Practice Address - Fax:212-598-5961
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-17
Last Update Date:2007-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048077183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01004984Medicaid