Provider Demographics
NPI:1679896377
Name:MELENGIC, JEAN ANN
Entity Type:Individual
Prefix:MS
First Name:JEAN
Middle Name:ANN
Last Name:MELENGIC
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:JEAN
Other - Middle Name:ANN
Other - Last Name:ARNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:335 NESCONSET HWY
Mailing Address - Street 2:
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-2516
Mailing Address - Country:US
Mailing Address - Phone:631-979-9121
Mailing Address - Fax:631-979-9125
Practice Address - Street 1:335 NESCONSET HWY
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-2516
Practice Address - Country:US
Practice Address - Phone:631-979-9121
Practice Address - Fax:631-979-9125
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-09
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049620183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01902941Medicaid