Provider Demographics
NPI:1124302971
Name:MELLECKER, MARTHA MEG (RPH, PHARMD)
Entity type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:MEG
Last Name:MELLECKER
Suffix:
Gender:F
Credentials:RPH, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3840 46TH AVE
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-7137
Mailing Address - Country:US
Mailing Address - Phone:309-794-1276
Mailing Address - Fax:309-794-9915
Practice Address - Street 1:3840 46TH AVE
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-7137
Practice Address - Country:US
Practice Address - Phone:309-794-1276
Practice Address - Fax:309-794-9915
Is Sole Proprietor?:No
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.295292183500000X
IA19194183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist