Provider Demographics
NPI:1982140141
Name:BLACK, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:BLACK
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 1:2046 NE WALDO RD
Mailing Address - Street 2:SUITE 3100
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32609-8975
Mailing Address - Country:US
Mailing Address - Phone:352-273-9045
Mailing Address - Fax:
Practice Address - Street 1:2046 NE WALDO RD
Practice Address - Street 2:SUITE 3100
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32609-8975
Practice Address - Country:US
Practice Address - Phone:352-273-9045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-12
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL14617183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist