Provider Demographics
NPI:1386931343
Name:KOMODA, MELISSA MISAO (PHARM D)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:MISAO
Last Name:KOMODA
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 W CHERRY LN
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1119
Mailing Address - Country:US
Mailing Address - Phone:208-884-5475
Mailing Address - Fax:
Practice Address - Street 1:3301 W CHERRY LN
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1119
Practice Address - Country:US
Practice Address - Phone:208-884-5475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6522183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist