Provider Demographics
NPI:1942305768
Name:TIEDEMAN, MELISSA MRACEK (PHARMD)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:MRACEK
Last Name:TIEDEMAN
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 1:8901 WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20889-0001
Mailing Address - Country:US
Mailing Address - Phone:202-615-2864
Mailing Address - Fax:
Practice Address - Street 1:8901 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20889-0001
Practice Address - Country:US
Practice Address - Phone:202-615-2864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD190941835P0018X
MN1186661835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist