Provider Demographics
NPI:1164014502
Name:ELLISON, SARA JANE
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:JANE
Last Name:ELLISON
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 1:2141 W EMORY RD
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37849-3704
Mailing Address - Country:US
Mailing Address - Phone:865-947-1581
Mailing Address - Fax:
Practice Address - Street 1:2141 W EMORY RD
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:TN
Practice Address - Zip Code:37849-3704
Practice Address - Country:US
Practice Address - Phone:865-947-1581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-08
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9140183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist