Provider Demographics
NPI:1780093245
Name:THOMAS, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:THOMAS
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 1:52482 INDIANA STATE ROUTE 933
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46637-3852
Mailing Address - Country:US
Mailing Address - Phone:574-271-0357
Mailing Address - Fax:
Practice Address - Street 1:52482 INDIANA STATE ROUTE 933
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46637-3852
Practice Address - Country:US
Practice Address - Phone:574-271-0357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-10
Last Update Date:2014-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26025744A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist