Provider Demographics
NPI:1164134045
Name:SAMIDE, MELISSA ROSE
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:ROSE
Last Name:SAMIDE
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 1:47 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-1023
Mailing Address - Country:US
Mailing Address - Phone:718-497-6692
Mailing Address - Fax:
Practice Address - Street 1:121 SAINT NICHOLAS AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-4043
Practice Address - Country:US
Practice Address - Phone:718-381-5116
Practice Address - Fax:718-417-3621
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-22
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY069690183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist