Healthcare Provider Details

I. General information

NPI: 1063749943
Provider Name (Legal Business Name): MELISSA HOTZE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2009
Last Update Date: 11/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18410 PRESTON RD
DALLAS TX
75252-5416
US

IV. Provider business mailing address

18410 PRESTON RD
DALLAS TX
75252-5416
US

V. Phone/Fax

Practice location:
  • Phone: 972-599-1004
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number46548
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number1-14579
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.287229
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: