Provider Demographics
NPI:1457636227
Name:ELLIOTT, AMY BETH (RPH)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:BETH
Last Name:ELLIOTT
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 1:672 FOX HOLLOW
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115
Mailing Address - Country:US
Mailing Address - Phone:815-756-4654
Mailing Address - Fax:
Practice Address - Street 1:100 WEST LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115
Practice Address - Country:US
Practice Address - Phone:815-756-1815
Practice Address - Fax:815-748-5527
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051041053183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist