Provider Demographics
NPI:1659882868
Name:TALLIS, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:TALLIS
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 1:288 HALL HILL RD
Mailing Address - Street 2:
Mailing Address - City:SOMERS
Mailing Address - State:CT
Mailing Address - Zip Code:06071-1401
Mailing Address - Country:US
Mailing Address - Phone:413-579-1565
Mailing Address - Fax:
Practice Address - Street 1:234 TOLLAND TPKE
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042-1744
Practice Address - Country:US
Practice Address - Phone:860-646-4832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-14
Last Update Date:2017-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0011778183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist