Provider Demographics
NPI:1710975800
Name:HARTMAN, MELISSA JEAN (RPH)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:JEAN
Last Name:HARTMAN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:JEAN
Other - Last Name:REYNOLDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:3923 NOTTINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-5533
Mailing Address - Country:US
Mailing Address - Phone:260-486-3471
Mailing Address - Fax:260-969-3879
Practice Address - Street 1:4900 SAINT JOE RD
Practice Address - Street 2:FORT WAYNE STATE DEVELOPMENTAL CENTER PHARMACY
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46835-3275
Practice Address - Country:US
Practice Address - Phone:260-969-1794
Practice Address - Fax:260-969-3879
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26015229A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist