Provider Demographics
NPI:1457441446
Name:ERNZEN, MELISSA ANN (PHARMD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:ERNZEN
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 1:302 COUNTRYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:EPWORTH
Mailing Address - State:IA
Mailing Address - Zip Code:52045-9523
Mailing Address - Country:US
Mailing Address - Phone:563-876-5599
Mailing Address - Fax:
Practice Address - Street 1:1920 ELM ST
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-3641
Practice Address - Country:US
Practice Address - Phone:563-583-7379
Practice Address - Fax:563-583-8846
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA19191183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0005058Medicaid