Provider Demographics
NPI:1346396769
Name:ELLISOR, REMBERT A JR (RPH)
Entity Type:Individual
Prefix:
First Name:REMBERT
Middle Name:A
Last Name:ELLISOR
Suffix:JR
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:PO BOX 93
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:SC
Mailing Address - Zip Code:29706-0093
Mailing Address - Country:US
Mailing Address - Phone:803-581-2102
Mailing Address - Fax:803-581-2121
Practice Address - Street 1:121 CHURCH ST
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:SC
Practice Address - Zip Code:29706-2903
Practice Address - Country:US
Practice Address - Phone:803-581-2102
Practice Address - Fax:803-581-2121
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6016183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist