Provider Demographics
NPI:1548858830
Name:MCMELLON, NICKLAUS ADAM (PHARMD)
Entity type:Individual
Prefix:
First Name:NICKLAUS
Middle Name:ADAM
Last Name:MCMELLON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8986 ORTEGA PARK DR
Mailing Address - Street 2:
Mailing Address - City:NAVARRE
Mailing Address - State:FL
Mailing Address - Zip Code:32566-4141
Mailing Address - Country:US
Mailing Address - Phone:850-936-6446
Mailing Address - Fax:850-936-6314
Practice Address - Street 1:8986 ORTEGA PARK DR
Practice Address - Street 2:
Practice Address - City:NAVARRE
Practice Address - State:FL
Practice Address - Zip Code:32566-4141
Practice Address - Country:US
Practice Address - Phone:850-936-6446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS56672183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist