Provider Demographics
NPI:1386945897
Name:MELLENCAMP, ANN (RPH)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:
Last Name:MELLENCAMP
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 WHITE SPAR RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86303-4626
Mailing Address - Country:US
Mailing Address - Phone:928-778-3098
Mailing Address - Fax:928-713-7474
Practice Address - Street 1:450 WHITE SPAR RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86303-4626
Practice Address - Country:US
Practice Address - Phone:928-778-3098
Practice Address - Fax:928-713-7474
Is Sole Proprietor?:No
Enumeration Date:2010-11-15
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8584183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist