Provider Demographics
NPI:1306516612
Name:BOLEK, MELISSA ANN (RPH)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:BOLEK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:ANN
Other - Last Name:EWERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1810 SILKS TER
Mailing Address - Street 2:
Mailing Address - City:GUTHRIE
Mailing Address - State:OK
Mailing Address - Zip Code:73044-7852
Mailing Address - Country:US
Mailing Address - Phone:405-564-4444
Mailing Address - Fax:
Practice Address - Street 1:1020 NW 192ND ST STE A
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73012-4296
Practice Address - Country:US
Practice Address - Phone:405-861-8800
Practice Address - Fax:405-861-8801
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-17
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK143091835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care