Provider Demographics
NPI:1619964319
Name:MELVIN, MARY SUSIE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:SUSIE
Last Name:MELVIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3111 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CHINCOTEAGUE ISLAND
Mailing Address - State:VA
Mailing Address - Zip Code:23336-1325
Mailing Address - Country:US
Mailing Address - Phone:757-336-6063
Mailing Address - Fax:
Practice Address - Street 1:6300 MADDOX BLVD
Practice Address - Street 2:
Practice Address - City:CHINCOTEAGUE ISLAND
Practice Address - State:VA
Practice Address - Zip Code:23336-2617
Practice Address - Country:US
Practice Address - Phone:757-336-3115
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0230000646183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician