Provider Demographics
NPI:1568744183
Name:ELLARS, JUSTIN
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:
Last Name:ELLARS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4625 WINEGARDNER RD NW
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:OH
Mailing Address - Zip Code:43783-9566
Mailing Address - Country:US
Mailing Address - Phone:740-252-2158
Mailing Address - Fax:740-654-2865
Practice Address - Street 1:4625 WINEGARDNER RD NW
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:OH
Practice Address - Zip Code:43783-9566
Practice Address - Country:US
Practice Address - Phone:740-252-2158
Practice Address - Fax:740-654-2865
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-10
Last Update Date:2011-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03226275183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist