Provider Demographics
NPI:1306014410
Name:MACK, MELVIN
Entity Type:Individual
Prefix:
First Name:MELVIN
Middle Name:
Last Name:MACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 SAYRE DR
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08540-5872
Mailing Address - Country:US
Mailing Address - Phone:609-520-9799
Mailing Address - Fax:
Practice Address - Street 1:2465 S BROAD ST
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:NJ
Practice Address - Zip Code:08610-4700
Practice Address - Country:US
Practice Address - Phone:609-503-0076
Practice Address - Fax:609-888-4604
Is Sole Proprietor?:No
Enumeration Date:2008-02-12
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ13370183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ13370OtherBOARD OF PHARMACY