Provider Demographics
NPI:1790999050
Name:ELLISOR, JENNIFER ROBIN (RPH, PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ROBIN
Last Name:ELLISOR
Suffix:
Gender:F
Credentials:RPH, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 PROFESSIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-4711
Mailing Address - Country:US
Mailing Address - Phone:803-794-6440
Mailing Address - Fax:803-739-1420
Practice Address - Street 1:101 PROFESSIONAL AVE
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-4711
Practice Address - Country:US
Practice Address - Phone:803-794-6440
Practice Address - Fax:803-739-1420
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC009029183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC009029OtherSTATE LICENSE