Provider Demographics
NPI:1457638041
Name:MELLOTT, TONY ROBERT (BS)
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:ROBERT
Last Name:MELLOTT
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 DIVISION AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97404-5419
Mailing Address - Country:US
Mailing Address - Phone:541-689-3965
Mailing Address - Fax:541-461-5972
Practice Address - Street 1:55 DIVISION AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97404-5419
Practice Address - Country:US
Practice Address - Phone:541-689-3965
Practice Address - Fax:541-461-5972
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-09
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0007349183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist