Provider Demographics
NPI:1164026365
Name:MCLALLEN, MELISSA BETH
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:BETH
Last Name:MCLALLEN
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 1:2212 CAMPOSTELLA RD
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23324-3073
Mailing Address - Country:US
Mailing Address - Phone:757-545-1002
Mailing Address - Fax:
Practice Address - Street 1:2212 CAMPOSTELLA RD
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23324-3073
Practice Address - Country:US
Practice Address - Phone:757-545-1002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-28
Last Update Date:2020-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202011090183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1952735912OtherRPH
VA1952735912Medicaid