Provider Demographics
NPI:1245515055
Name:ETHERIDGE, MELISSA JENNIFER (PHARMACISTS)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:JENNIFER
Last Name:ETHERIDGE
Suffix:
Gender:F
Credentials:PHARMACISTS
Other - Prefix:DR
Other - First Name:MELISSA
Other - Middle Name:JENNIFER
Other - Last Name:ETHERIDGE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMD
Mailing Address - Street 1:405 OLD HOUSE RD UNIT 101
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:SC
Mailing Address - Zip Code:29936
Mailing Address - Country:US
Mailing Address - Phone:843-645-8388
Mailing Address - Fax:843-645-8389
Practice Address - Street 1:405 OLD HOUSE RD
Practice Address - Street 2:UNIT 101
Practice Address - City:RIDGELAND
Practice Address - State:SC
Practice Address - Zip Code:29936
Practice Address - Country:US
Practice Address - Phone:843-645-8388
Practice Address - Fax:843-645-8389
Is Sole Proprietor?:No
Enumeration Date:2011-10-13
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12000183500000X, 1835N0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835N0905XPharmacy Service ProvidersPharmacistNuclear
No183500000XPharmacy Service ProvidersPharmacist