Provider Demographics
NPI:1821689290
Name:MATHEW, MELISSA (PHARMD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:MATHEW
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 1:10S135 PALISADES RD
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-5807
Mailing Address - Country:US
Mailing Address - Phone:940-297-5592
Mailing Address - Fax:
Practice Address - Street 1:1002 S BUSSE RD
Practice Address - Street 2:
Practice Address - City:MT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-4570
Practice Address - Country:US
Practice Address - Phone:847-871-6291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-28
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.303210183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist