Provider Demographics
NPI:1639469083
Name:ELLINGSON, JOANNA
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:
Last Name:ELLINGSON
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:PO BOX 1501
Mailing Address - Street 2:
Mailing Address - City:WEST POINT
Mailing Address - State:VA
Mailing Address - Zip Code:23181-1501
Mailing Address - Country:US
Mailing Address - Phone:804-843-2880
Mailing Address - Fax:804-843-4004
Practice Address - Street 1:14TH & MAIN ST.
Practice Address - Street 2:
Practice Address - City:WEST POINT
Practice Address - State:VA
Practice Address - Zip Code:23181
Practice Address - Country:US
Practice Address - Phone:804-843-2880
Practice Address - Fax:804-843-4004
Is Sole Proprietor?:No
Enumeration Date:2011-04-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202206635183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist