Healthcare Provider Details

I. General information

NPI: 1497368567
Provider Name (Legal Business Name): MELVINA LAKE PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2020
Last Update Date: 08/28/2020
Certification Date: 08/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US HIGHWAY 491 NORTH
SHIPROCK NM
87420
US

IV. Provider business mailing address

HWY 491 NORTH
SHIPROCK NM
87420
US

V. Phone/Fax

Practice location:
  • Phone: 505-368-6001
  • Fax:
Mailing address:
  • Phone: 505-368-7250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberP8897
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: