Provider Demographics
NPI:1578668901
Name:ELLISVILLE STATE SCHOOL
Entity Type:Organization
Organization Name:ELLISVILLE STATE SCHOOL
Other - Org Name:ELLISVILLE STATE SCHOOL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHCY DIR
Authorized Official - Prefix:
Authorized Official - First Name:PATTI
Authorized Official - Middle Name:
Authorized Official - Last Name:WELCH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:601-477-5784
Mailing Address - Street 1:1101 HIGHWAY 11 S
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39437-4443
Mailing Address - Country:US
Mailing Address - Phone:601-477-5785
Mailing Address - Fax:601-477-5687
Practice Address - Street 1:1101 HIGHWAY 11 S
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39437-4443
Practice Address - Country:US
Practice Address - Phone:601-477-5785
Practice Address - Fax:601-477-5687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MS011850313336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2050712OtherPK
MS00030384Medicaid
2503248OtherNCPDP