Provider Demographics
NPI:1497957690
Name:ELLERUP, JOHANNA KRISTIN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JOHANNA
Middle Name:KRISTIN
Last Name:ELLERUP
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 N MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:N MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-2636
Mailing Address - Country:US
Mailing Address - Phone:516-509-8185
Mailing Address - Fax:516-799-8286
Practice Address - Street 1:99 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:NORTH MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-2636
Practice Address - Country:US
Practice Address - Phone:516-509-8185
Practice Address - Fax:516-799-8286
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY079733183500000X
NY0554681835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist