Provider Demographics
NPI:1033422993
Name:BLOCH, ELLIS ANTHONY
Entity Type:Individual
Prefix:
First Name:ELLIS
Middle Name:ANTHONY
Last Name:BLOCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12671 MONTEREY CYPRESS WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-2423
Mailing Address - Country:US
Mailing Address - Phone:858-361-4332
Mailing Address - Fax:858-581-4224
Practice Address - Street 1:4605 MORENA BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-3650
Practice Address - Country:US
Practice Address - Phone:858-581-4550
Practice Address - Fax:858-581-4224
Is Sole Proprietor?:No
Enumeration Date:2010-07-21
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42003183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist