Provider Demographics
NPI:1275261562
Name:MELLOTT, LENISE J (PHARMD)
Entity Type:Individual
Prefix:
First Name:LENISE
Middle Name:J
Last Name:MELLOTT
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9153 BUGABOO DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80924-4552
Mailing Address - Country:US
Mailing Address - Phone:970-556-8222
Mailing Address - Fax:
Practice Address - Street 1:9153 BUGABOO DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80924-4552
Practice Address - Country:US
Practice Address - Phone:970-556-8222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-12
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO12607183500000X
KS11099183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist