Healthcare Provider Details

I. General information

NPI: 1245672559
Provider Name (Legal Business Name): MELISSA NICOLE MCINNIS PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2013
Last Update Date: 07/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 S 5TH AVE PHARMACY (119)
HINES IL
60141-3030
US

IV. Provider business mailing address

5000 S 5TH AVE PHARMACY (119)
HINES IL
60141-3030
US

V. Phone/Fax

Practice location:
  • Phone: 708-202-8387
  • Fax: 708-202-4768
Mailing address:
  • Phone: 708-202-8387
  • Fax: 708-202-4768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051296688
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: