1689274037 NPI number — DR. VANESSA LYNN MELLOTT PHARM. D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689274037 NPI number — DR. VANESSA LYNN MELLOTT PHARM. D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MELLOTT
Provider First Name:
VANESSA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARM. D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MELLOTT
Provider Other First Name:
VANNESSA
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHARM. D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1689274037
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/27/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6285 E WAVERLY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INVERNESS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34452-8121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-257-2353
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1936 N LECANTO HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LECANTO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34461-9680
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-228-6003
Provider Business Practice Location Address Fax Number:
352-228-6004
Provider Enumeration Date:
10/27/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  PS49486 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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