Provider Demographics
NPI:1235228461
Name:ELLIS, PATRI (RPH)
Entity Type:Individual
Prefix:
First Name:PATRI
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 S CHURCH AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39339-2921
Mailing Address - Country:US
Mailing Address - Phone:662-773-7847
Mailing Address - Fax:662-773-7844
Practice Address - Street 1:403 S CHURCH AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39339-2921
Practice Address - Country:US
Practice Address - Phone:662-773-7847
Practice Address - Fax:662-773-7844
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS01826/01.1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00030300Medicaid
MS2514063OtherNABP NUMBER
MSAD3044601OtherDEA NUMBER