Provider Demographics
NPI:1790040863
Name:ELLIS, TIMOTHY MICHAEL (PHARMD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:MICHAEL
Last Name:ELLIS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 LAURELHART LANE
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681
Mailing Address - Country:US
Mailing Address - Phone:864-714-9899
Mailing Address - Fax:
Practice Address - Street 1:26 LAURELHART LN
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29281-3909
Practice Address - Country:US
Practice Address - Phone:864-714-9899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-05
Last Update Date:2021-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13922183500000X
NC22700183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist