Basic Information
| Provider Information | |||||||||
| NPI: | 1871825000 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUDSON | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | R.PH. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2215 PORTLAND AVE | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402121033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5027748631 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2215 PORTLAND AVE | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402121033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5027748631 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2010 | ||||||||
| LastUpdateDate: | 11/11/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P0018X | 011687 | KY | Y | Pharmacy Service Providers | Pharmacist | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist | 1835P0018X | 26021042A | IN | N | Pharmacy Service Providers | Pharmacist | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist |
ID Information
| ID | Type | State | Issuer | Description | 011687 | 01 | KY | KY BOARD OF PHARMACY | OTHER | 26021042A | 01 | IN | IN BOARD OF PHARMACY | OTHER |