Provider Demographics
NPI:1457481210
Name:ELLIS, KENT A
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:A
Last Name:ELLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:KENT
Other - Middle Name:A
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:96 TENPENNY ST
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04032-6760
Mailing Address - Country:US
Mailing Address - Phone:720-624-9730
Mailing Address - Fax:
Practice Address - Street 1:144 STATE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-3776
Practice Address - Country:US
Practice Address - Phone:207-553-6787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR37881835X0200X
ME119001835X0200X
OR107511835X0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835X0200XPharmacy Service ProvidersPharmacistOncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
015812OtherKAISER-COMMERCIAL NUMBER