Provider Demographics
NPI:1710028865
Name:BOLTON, MELODY THOMPSON (RPH)
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:THOMPSON
Last Name:BOLTON
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 1:795 MELTON RD
Mailing Address - Street 2:
Mailing Address - City:BAKER
Mailing Address - State:FL
Mailing Address - Zip Code:32531-5323
Mailing Address - Country:US
Mailing Address - Phone:850-537-4259
Mailing Address - Fax:850-537-4258
Practice Address - Street 1:5809 HIGHWAY 189 N
Practice Address - Street 2:
Practice Address - City:BAKER
Practice Address - State:FL
Practice Address - Zip Code:32531-2501
Practice Address - Country:US
Practice Address - Phone:850-537-6266
Practice Address - Fax:850-537-6350
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS27821183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist