Provider Demographics
NPI:1659706299
Name:ELLIS, CHARLES BEN (RPH)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:BEN
Last Name:ELLIS
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 1:119 COTTAGE AVE
Mailing Address - Street 2:
Mailing Address - City:CASHMERE
Mailing Address - State:WA
Mailing Address - Zip Code:98815-1001
Mailing Address - Country:US
Mailing Address - Phone:509-782-2717
Mailing Address - Fax:509-782-3262
Practice Address - Street 1:119 COTTAGE AVE
Practice Address - Street 2:
Practice Address - City:CASHMERE
Practice Address - State:WA
Practice Address - Zip Code:98815-1001
Practice Address - Country:US
Practice Address - Phone:509-782-2717
Practice Address - Fax:509-782-3262
Is Sole Proprietor?:No
Enumeration Date:2013-09-12
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00010252183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist