Provider Demographics
NPI:1639466758
Name:SOUKUP, MELISSA CATHERINE GABBERT (PHARM D)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:CATHERINE GABBERT
Last Name:SOUKUP
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 1:18275 KENRICK AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-7306
Mailing Address - Country:US
Mailing Address - Phone:952-892-5454
Mailing Address - Fax:952-892-5454
Practice Address - Street 1:18275 KENRICK AVE
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-7306
Practice Address - Country:US
Practice Address - Phone:952-892-5454
Practice Address - Fax:952-892-5454
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-10
Last Update Date:2011-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN118640183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist