Provider Demographics
NPI:1235219395
Name:ANDERSON, MELANIE JO
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:JO
Last Name:ANDERSON
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 1:1105 STANFORD LAKE RD
Mailing Address - Street 2:
Mailing Address - City:POPLARVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39470-9203
Mailing Address - Country:US
Mailing Address - Phone:601-795-0496
Mailing Address - Fax:
Practice Address - Street 1:2800 LINCOLN RD
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-3124
Practice Address - Country:US
Practice Address - Phone:601-268-2780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST08058183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist