Provider Demographics
NPI:1831318849
Name:BLACKMAN, MELONEZE RENEE
Entity Type:Individual
Prefix:MISS
First Name:MELONEZE
Middle Name:RENEE
Last Name:BLACKMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22777 W 11 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-2152
Mailing Address - Country:US
Mailing Address - Phone:248-358-0727
Mailing Address - Fax:248-358-9394
Practice Address - Street 1:22777 W 11 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-2152
Practice Address - Country:US
Practice Address - Phone:248-358-0727
Practice Address - Fax:248-358-9394
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI300101041151852183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician