Provider Demographics
NPI:1821291022
Name:REALE, MELISSA DIANE (PHARMD)
Entity Type:Individual
Prefix:MISS
First Name:MELISSA
Middle Name:DIANE
Last Name:REALE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 IVY LN
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13219-2810
Mailing Address - Country:US
Mailing Address - Phone:315-420-4548
Mailing Address - Fax:
Practice Address - Street 1:5206 W GENESEE ST
Practice Address - Street 2:
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-2202
Practice Address - Country:US
Practice Address - Phone:315-468-1701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051014183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist