Provider Demographics
NPI:1568715944
Name:MELIS, GARY A (RPH)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:A
Last Name:MELIS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1621 W MARQUETTE ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-2287
Mailing Address - Country:US
Mailing Address - Phone:920-205-5617
Mailing Address - Fax:
Practice Address - Street 1:1621 W MARQUETTE ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-2287
Practice Address - Country:US
Practice Address - Phone:920-205-5617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-22
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9122040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist