Provider Demographics
NPI:1417551631
Name:ELLIOTT, MONICA LORRAINE
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:LORRAINE
Last Name:ELLIOTT
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 1:2383 RED SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:BRUTUS
Mailing Address - State:MI
Mailing Address - Zip Code:49716-9727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:630 W MITCHELL ST
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2233
Practice Address - Country:US
Practice Address - Phone:231-347-8282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-29
Last Update Date:2020-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302413122183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist