MEDICARE: MELROSE PHARMACY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	28907	TX

General Provider Information

NPI Number	:	1124459870
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MELROSE PHARMACY LLC

Provider Business Mailing Address
First Line	:	2860 HIGHWAY 157 N STE 120
Second Line	:
City	:	MANSFIELD
State	:	TX
Zip	:	76063-8883
Country	:	US
Telephone Number	:	817-453-4444
Fax Number	:

Provider Business Practice Location Address
First Line	:	2860 HIGHWAY 157 N STE 120
Second Line	:
City	:	MANSFIELD
State	:	TX
Zip	:	76063-8883
Country	:	US
Telephone Number	:	817-453-4444
Fax Number	:

Authorized Official
Title or Position	:	OFFICER
Name	:	TERESA B NGUYEN
Credential	:	PHARMD
Telephone Number	:	817-453-4444

Provider Enumeration Date	:	12/06/2013
Last Update Date	:	12/06/2013

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