Provider Demographics
NPI:1689172694
Name:MELTON, LAURA FITZGERALD
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:FITZGERALD
Last Name:MELTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:ANN
Other - Last Name:FITZGERALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:589 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38506-5320
Mailing Address - Country:US
Mailing Address - Phone:931-537-3850
Mailing Address - Fax:931-537-3846
Practice Address - Street 1:589 W MAIN ST
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38506-5320
Practice Address - Country:US
Practice Address - Phone:931-537-3850
Practice Address - Fax:931-537-3846
Is Sole Proprietor?:No
Enumeration Date:2018-01-24
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN34381183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist