Healthcare Provider Details

I. General information

NPI: 1639044456
Provider Name (Legal Business Name): TATIANA V MELNIK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2025
Last Update Date: 09/18/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

977 US - 98 E
DESTIN FL
32541
US

IV. Provider business mailing address

1013 CORSICA LN
LAS VEGAS NV
89144-1252
US

V. Phone/Fax

Practice location:
  • Phone: 850-650-4538
  • Fax:
Mailing address:
  • Phone: 702-513-0850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPS70446
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: