Provider Demographics
NPI:1437429172
Name:ELIS, DIANE L (RPH)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:L
Last Name:ELIS
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 1:12359 WITHERIDGE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-5728
Mailing Address - Country:US
Mailing Address - Phone:813-968-3334
Mailing Address - Fax:
Practice Address - Street 1:15602 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-1606
Practice Address - Country:US
Practice Address - Phone:813-264-7722
Practice Address - Fax:813-963-5823
Is Sole Proprietor?:No
Enumeration Date:2012-01-11
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS31971183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist