Provider Demographics
NPI:1689987760
Name:MELLYN, JACQUELINE (RPH)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:MELLYN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1935 N STAPLEY DR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203-2749
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1935 N STAPLEY DR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85203-2749
Practice Address - Country:US
Practice Address - Phone:480-610-4173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-19
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS007339183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist