Provider Demographics
NPI:1639497597
Name:MANCUSO, MELISSA C (R,PH)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:C
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:R,PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5504 CANYON BLUFF CT
Mailing Address - Street 2:
Mailing Address - City:ROSHARON
Mailing Address - State:TX
Mailing Address - Zip Code:77583-2090
Mailing Address - Country:US
Mailing Address - Phone:281-431-7517
Mailing Address - Fax:
Practice Address - Street 1:5225 BUFFALO SPEEDWAY
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77005-4210
Practice Address - Country:US
Practice Address - Phone:713-218-1850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-17
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33311183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist