Provider Demographics
NPI:1629257571
Name:JEANTY, MELISSA MARIE (PHARM D)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARIE
Last Name:JEANTY
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GOWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14070-1318
Mailing Address - Country:US
Mailing Address - Phone:716-532-4114
Mailing Address - Fax:
Practice Address - Street 1:81 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GOWANDA
Practice Address - State:NY
Practice Address - Zip Code:14070-1318
Practice Address - Country:US
Practice Address - Phone:716-532-4114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-29
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051892183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist