Provider Demographics
NPI:1578538815
Name:MCMELLON, PAUL (RPH)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:
Last Name:MCMELLON
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 1:2351 DUNSFORD RD
Mailing Address - Street 2:
Mailing Address - City:JAY
Mailing Address - State:FL
Mailing Address - Zip Code:32565-2941
Mailing Address - Country:US
Mailing Address - Phone:850-936-6446
Mailing Address - Fax:
Practice Address - Street 1:8986 ORTEGA PARK DR
Practice Address - Street 2:
Practice Address - City:NAVARRE
Practice Address - State:FL
Practice Address - Zip Code:32566-4141
Practice Address - Country:US
Practice Address - Phone:850-936-6446
Practice Address - Fax:850-936-6314
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS0022910183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL21762OtherCONTROLLED SUBSTANCE