Provider Demographics
NPI:1881065365
Name:BALLAK, MELISSA THERESA (PHARMD)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:THERESA
Last Name:BALLAK
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 1:1936 LEXINGTON AVE APT A
Mailing Address - Street 2:
Mailing Address - City:GREAT LAKES
Mailing Address - State:IL
Mailing Address - Zip Code:60088-1048
Mailing Address - Country:US
Mailing Address - Phone:815-549-7407
Mailing Address - Fax:
Practice Address - Street 1:1400 E LAKE-COOK ROAD
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:IL
Practice Address - Zip Code:60090
Practice Address - Country:US
Practice Address - Phone:847-215-5055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-09
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051299115183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist