Provider Demographics
NPI:1831412782
Name:ATHANAS, MELISSA (RPH)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:ATHANAS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:PULTORAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:4716 LAWSHER DR
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13215-2322
Mailing Address - Country:US
Mailing Address - Phone:315-469-1596
Mailing Address - Fax:
Practice Address - Street 1:4001 S SALINA ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13205-2088
Practice Address - Country:US
Practice Address - Phone:315-469-1701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-07
Last Update Date:2010-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042941183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist