Provider Demographics
NPI:1194010090
Name:ELLIS, BRIAN ERIC (RPH)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:ERIC
Last Name:ELLIS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 MARKETPLACE DR
Mailing Address - Street 2:T-1002
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014-4310
Mailing Address - Country:US
Mailing Address - Phone:410-638-9031
Mailing Address - Fax:410-638-9031
Practice Address - Street 1:580 MARKETPLACE DR
Practice Address - Street 2:T-1002
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-4310
Practice Address - Country:US
Practice Address - Phone:410-638-9031
Practice Address - Fax:410-638-9031
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD11755183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist