Provider Demographics
NPI:1457628026
Name:ELLIOTT, EDWIN PAUL (PHARMD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:PAUL
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22521 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2122
Mailing Address - Country:US
Mailing Address - Phone:313-278-1515
Mailing Address - Fax:
Practice Address - Street 1:22521 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2122
Practice Address - Country:US
Practice Address - Phone:313-278-1515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-25
Last Update Date:2011-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302038311183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist