Provider Demographics
NPI:1184259921
Name:VANN, MELLIE ROSE
Entity type:Individual
Prefix:
First Name:MELLIE ROSE
Middle Name:
Last Name:VANN
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 1:5340 HAYTON WAY
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-2579
Mailing Address - Country:US
Mailing Address - Phone:941-448-9469
Mailing Address - Fax:
Practice Address - Street 1:1750 TOMCAT BLVD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23460-2168
Practice Address - Country:US
Practice Address - Phone:757-953-3933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202216011183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist