Provider Demographics
NPI:1609949544
Name:MELCONS PHARMACY
Entity Type:Organization
Organization Name:MELCONS PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:CARMEN
Authorized Official - Last Name:SPENILLO
Authorized Official - Suffix:
Authorized Official - Credentials:RP
Authorized Official - Phone:973-427-1234
Mailing Address - Street 1:207 DIAMOND BRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07506-1901
Mailing Address - Country:US
Mailing Address - Phone:973-427-1234
Mailing Address - Fax:973-427-6624
Practice Address - Street 1:207 DIAMOND BRIDGE AVE
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:NJ
Practice Address - Zip Code:07506-1901
Practice Address - Country:US
Practice Address - Phone:973-427-1234
Practice Address - Fax:973-427-6624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
NJ28RS003722003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
0752700001Medicare NSC