Provider Demographics
NPI:1376321117
Name:MOMMAERTS, MELANIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:MOMMAERTS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:
Other - Last Name:YANZICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:200 1ST ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55905-0001
Mailing Address - Country:US
Mailing Address - Phone:715-597-2575
Mailing Address - Fax:
Practice Address - Street 1:13025 8TH ST
Practice Address - Street 2:
Practice Address - City:OSSEO
Practice Address - State:WI
Practice Address - Zip Code:54758-7634
Practice Address - Country:US
Practice Address - Phone:920-619-0307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-21
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17105-401835P2201X
WI17105183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care