Provider Demographics
NPI:1568066009
Name:ELLIS, STEPHEN (PHARMD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:ELLIS
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 1:4232 NE OCEAN BLVD
Mailing Address - Street 2:
Mailing Address - City:JENSEN BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:34957-4307
Mailing Address - Country:US
Mailing Address - Phone:772-225-9800
Mailing Address - Fax:
Practice Address - Street 1:4232 NE OCEAN BLVD
Practice Address - Street 2:
Practice Address - City:JENSEN BEACH
Practice Address - State:FL
Practice Address - Zip Code:34957-4307
Practice Address - Country:US
Practice Address - Phone:772-225-9800
Practice Address - Fax:772-225-4840
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-25
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS45763183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist