Provider Demographics
NPI:1639696008
Name:KALLAS, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:KALLAS
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 1:97 MARKET POINT DR APT 726
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-4181
Mailing Address - Country:US
Mailing Address - Phone:803-984-9518
Mailing Address - Fax:
Practice Address - Street 1:1509 ROPER MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-5601
Practice Address - Country:US
Practice Address - Phone:864-230-1082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-27
Last Update Date:2017-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37353183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist