Provider Demographics
NPI:1154827442
Name:ELLIS, MELODY
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:
Last Name:ELLIS
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 1:1 HIGH ST APT 415
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-3814
Mailing Address - Country:US
Mailing Address - Phone:757-879-6955
Mailing Address - Fax:
Practice Address - Street 1:620 JOHN PAUL JONES CIR
Practice Address - Street 2:NAVAL MEDICAL CENTER PORTSMOUTH
Practice Address - City:PORSTMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23708-2370
Practice Address - Country:US
Practice Address - Phone:757-953-0284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-04
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0230023795183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0230023795OtherVIRGINIA BOARD OF PHARMACY