Provider Demographics
NPI:1710902705
Name:ELLIOTTS PHARMACY INC.
Entity Type:Organization
Organization Name:ELLIOTTS PHARMACY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASHE
Authorized Official - Middle Name:
Authorized Official - Last Name:WAHBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-460-2614
Mailing Address - Street 1:4835 EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422-2759
Mailing Address - Country:US
Mailing Address - Phone:805-460-2609
Mailing Address - Fax:805-460-2611
Practice Address - Street 1:4835 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-2759
Practice Address - Country:US
Practice Address - Phone:805-460-2609
Practice Address - Fax:805-460-2611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY462393336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA462390Medicaid
CAPHA462390Medicaid