Provider Demographics
NPI:1376672634
Name:MELLA, ELSA M
Entity Type:Individual
Prefix:
First Name:ELSA
Middle Name:M
Last Name:MELLA
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:G2 CALLE VIOLETA
Mailing Address - Street 2:REPARTO VALENCIA
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00959-4139
Mailing Address - Country:US
Mailing Address - Phone:787-780-7245
Mailing Address - Fax:
Practice Address - Street 1:X1 CALLE 17
Practice Address - Street 2:ROYAL TOWN
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00956-4534
Practice Address - Country:US
Practice Address - Phone:787-620-9609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1164183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician