Provider Demographics
NPI:1902247869
Name:MELUGIN, DAX OWEN
Entity Type:Individual
Prefix:
First Name:DAX
Middle Name:OWEN
Last Name:MELUGIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 WARD AVE
Mailing Address - Street 2:
Mailing Address - City:CARUTHERSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63830-1451
Mailing Address - Country:US
Mailing Address - Phone:573-333-4890
Mailing Address - Fax:573-333-0306
Practice Address - Street 1:410 WARD AVE
Practice Address - Street 2:
Practice Address - City:CARUTHERSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63830-1451
Practice Address - Country:US
Practice Address - Phone:573-333-4890
Practice Address - Fax:573-333-0306
Is Sole Proprietor?:No
Enumeration Date:2013-07-08
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009035365183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist