Provider Demographics
NPI:1508148057
Name:ELLEGANT, MIRIAM (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MIRIAM
Middle Name:
Last Name:ELLEGANT
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 1:103 SAWYER CIR
Mailing Address - Street 2:APT 459
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-5950
Mailing Address - Country:US
Mailing Address - Phone:901-230-6234
Mailing Address - Fax:
Practice Address - Street 1:3360 N WATKINS ST
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38127-6432
Practice Address - Country:US
Practice Address - Phone:901-353-4603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-11
Last Update Date:2011-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN24405183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist