Provider Demographics
NPI:1508143967
Name:HAWTHORNE, MELINDA ANN (DPH)
Entity Type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:ANN
Last Name:HAWTHORNE
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CHOCTAW WAY
Mailing Address - Street 2:
Mailing Address - City:TALIHINA
Mailing Address - State:OK
Mailing Address - Zip Code:74571-2022
Mailing Address - Country:US
Mailing Address - Phone:918-567-7000
Mailing Address - Fax:918-567-7037
Practice Address - Street 1:1 CHOCTAW WAY
Practice Address - Street 2:
Practice Address - City:TALIHINA
Practice Address - State:OK
Practice Address - Zip Code:74571-2022
Practice Address - Country:US
Practice Address - Phone:918-567-7000
Practice Address - Fax:918-567-7037
Is Sole Proprietor?:No
Enumeration Date:2011-11-12
Last Update Date:2011-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11851183500000X
ARPD08392183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist