Provider Demographics
NPI:1760464234
Name:JELLISON, MARK GARREY (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:GARREY
Last Name:JELLISON
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:371 LUDLOW AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45220-2018
Mailing Address - Country:US
Mailing Address - Phone:513-484-9287
Mailing Address - Fax:
Practice Address - Street 1:371 LUDLOW AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45220-2018
Practice Address - Country:US
Practice Address - Phone:513-484-9287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2020-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-2-13810183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist