Provider Demographics
NPI:1689854218
Name:MUI-TELLADO, ELLEN (RPH)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:
Last Name:MUI-TELLADO
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6962 188TH ST
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-3771
Mailing Address - Country:US
Mailing Address - Phone:718-969-2890
Mailing Address - Fax:718-969-2979
Practice Address - Street 1:6962 188TH ST
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-3771
Practice Address - Country:US
Practice Address - Phone:718-969-2890
Practice Address - Fax:718-969-2979
Is Sole Proprietor?:No
Enumeration Date:2007-11-12
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043351183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02717408Medicaid