Provider Demographics
NPI:1265010813
Name:MELLACE, MICHAEL J (RPH)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:MELLACE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:338 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109-5231
Mailing Address - Country:US
Mailing Address - Phone:973-759-1956
Mailing Address - Fax:
Practice Address - Street 1:338 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109-5231
Practice Address - Country:US
Practice Address - Phone:973-759-1956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-01
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI04115500183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist