Provider Demographics
NPI:1518579556
Name:EZELL, CASSANDRA LEANN
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:LEANN
Last Name:EZELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8000 MADISON BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-2035
Mailing Address - Country:US
Mailing Address - Phone:256-461-6903
Mailing Address - Fax:256-464-8457
Practice Address - Street 1:8000 MADISON BLVD STE B
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-2035
Practice Address - Country:US
Practice Address - Phone:256-461-6903
Practice Address - Fax:256-464-8457
Is Sole Proprietor?:No
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL19975183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist