MEDICARE: MRS. MELISSA JEAN HARTMAN R.PH.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	26015229A	IN

General Provider Information

NPI Number	:	1710975800
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MELISSA JEAN HARTMAN R.PH.

Provider Business Mailing Address
First Line	:	3923 NOTTINGHAM DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-5533
Country	:	US
Telephone Number	:	260-486-3471
Fax Number	:	260-969-3879

Provider Business Practice Location Address
First Line	:	4900 SAINT JOE RD
Second Line	:	FORT WAYNE STATE DEVELOPMENTAL CENTER PHARMACY
City	:	FORT WAYNE
State	:	IN
Zip	:	46835-3275
Country	:	US
Telephone Number	:	260-969-1794
Fax Number	:	260-969-3879

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/12/2005
Last Update Date	:	07/08/2007

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