Provider Demographics
NPI:1124366703
Name:ELLIS, CHARLES K (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:K
Last Name:ELLIS
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 SHEPHERD RD
Mailing Address - Street 2:
Mailing Address - City:MULBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:33860-8699
Mailing Address - Country:US
Mailing Address - Phone:863-644-5929
Mailing Address - Fax:
Practice Address - Street 1:2040 SHEPHERD RD
Practice Address - Street 2:
Practice Address - City:MULBERRY
Practice Address - State:FL
Practice Address - Zip Code:33860-8699
Practice Address - Country:US
Practice Address - Phone:863-644-5929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-16
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS32584183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist