Provider Demographics
NPI:1184227530
Name:DISANTIS, ELLINA
Entity Type:Individual
Prefix:
First Name:ELLINA
Middle Name:
Last Name:DISANTIS
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 1:6231 SOM CENTER RD
Mailing Address - Street 2:
Mailing Address - City:SOLON
Mailing Address - State:OH
Mailing Address - Zip Code:44139-2912
Mailing Address - Country:US
Mailing Address - Phone:440-248-9239
Mailing Address - Fax:
Practice Address - Street 1:6231 SOM CENTER RD
Practice Address - Street 2:
Practice Address - City:SOLON
Practice Address - State:OH
Practice Address - Zip Code:44139-2912
Practice Address - Country:US
Practice Address - Phone:440-248-9239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03233248183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist