Provider Demographics
NPI:1023705183
Name:MELTON, AUDRA DELORES (PHARMD)
Entity type:Individual
Prefix:MS
First Name:AUDRA
Middle Name:DELORES
Last Name:MELTON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7383 GRAND AVE APT 206
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60516-4138
Mailing Address - Country:US
Mailing Address - Phone:773-391-4806
Mailing Address - Fax:
Practice Address - Street 1:15575 E 127TH ST
Practice Address - Street 2:
Practice Address - City:LEMONT
Practice Address - State:IL
Practice Address - Zip Code:60439-4433
Practice Address - Country:US
Practice Address - Phone:630-257-9250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.305441183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist