Provider Demographics
NPI:1689285264
Name:SCOTT, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:SCOTT
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 1:6021 E OLD TRAIL RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46725-8860
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13821 LEO RD
Practice Address - Street 2:
Practice Address - City:LEO
Practice Address - State:IN
Practice Address - Zip Code:46765-9400
Practice Address - Country:US
Practice Address - Phone:260-627-8616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-16
Last Update Date:2020-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26022902A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist