Provider Demographics
NPI:1619086709
Name:ELLEXSON, CHARLES RAY (RPH)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:RAY
Last Name:ELLEXSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4774 OLD HIGHWAY 70
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-0704
Mailing Address - Country:US
Mailing Address - Phone:580-924-4549
Mailing Address - Fax:
Practice Address - Street 1:1201 E 9TH ST
Practice Address - Street 2:
Practice Address - City:BONHAM
Practice Address - State:TX
Practice Address - Zip Code:75418-4059
Practice Address - Country:US
Practice Address - Phone:903-583-6787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8283183500000X
TX28257183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist