Provider Demographics
NPI:1700967700
Name:MOUNTS, MELINDA SUE
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:SUE
Last Name:MOUNTS
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 1:410 S FRONT ST
Mailing Address - Street 2:
Mailing Address - City:BRAIDWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60408-2007
Mailing Address - Country:US
Mailing Address - Phone:815-458-3810
Mailing Address - Fax:
Practice Address - Street 1:122 DEPOT ST
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:IL
Practice Address - Zip Code:60424
Practice Address - Country:US
Practice Address - Phone:815-237-2152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician