Provider Demographics
NPI:1437838471
Name:HACKWORTH, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:HACKWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18935 KROSS RD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92508-8831
Mailing Address - Country:US
Mailing Address - Phone:909-488-2912
Mailing Address - Fax:
Practice Address - Street 1:4210 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:CA
Practice Address - Zip Code:92346-2742
Practice Address - Country:US
Practice Address - Phone:909-425-8687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-17
Last Update Date:2025-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86323183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist