Provider Demographics
NPI:1659633600
Name:STODDARD, ELLWOOD HERBERT (RPH)
Entity Type:Individual
Prefix:MR
First Name:ELLWOOD
Middle Name:HERBERT
Last Name:STODDARD
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 1:100 CANAVERAL PLAZA BLVD
Mailing Address - Street 2:
Mailing Address - City:COCOA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32931-3520
Mailing Address - Country:US
Mailing Address - Phone:321-868-2287
Mailing Address - Fax:321-784-8768
Practice Address - Street 1:100 CANAVERAL PLAZA BLVD
Practice Address - Street 2:
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-3520
Practice Address - Country:US
Practice Address - Phone:321-868-2287
Practice Address - Fax:321-784-8768
Is Sole Proprietor?:No
Enumeration Date:2012-06-14
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS0012737183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist