Healthcare Provider Details

I. General information

NPI: 1659665651
Provider Name (Legal Business Name): DR. MELISSA LYNN FORMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2011
Last Update Date: 06/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5001 UNIVERSITY TOWN CENTRE DR T-1949
MORGANTOWN WV
26501-2267
US

IV. Provider business mailing address

5001 UNIVERSITY TOWN CENTRE DR T-1949
MORGANTOWN WV
26501-2267
US

V. Phone/Fax

Practice location:
  • Phone: 304-599-5581
  • Fax:
Mailing address:
  • Phone: 304-599-5581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5629
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: