Provider Demographics
NPI:1396365219
Name:JELLOTS, CALLIE RAE (PHARMD)
Entity Type:Individual
Prefix:
First Name:CALLIE
Middle Name:RAE
Last Name:JELLOTS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1295 WATER ST
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-1625
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:645 KOLTER DR
Practice Address - Street 2:
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701-3570
Practice Address - Country:US
Practice Address - Phone:724-349-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-21
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP449456183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty