Provider Demographics
NPI:1811584626
Name:ELLIS, JENNIFER KYLEEN
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:KYLEEN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2604 PEACH ORCHARD RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30906-2489
Mailing Address - Country:US
Mailing Address - Phone:706-798-5645
Mailing Address - Fax:706-798-0377
Practice Address - Street 1:2604 PEACH ORCHARD RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906-2489
Practice Address - Country:US
Practice Address - Phone:706-798-5645
Practice Address - Fax:706-798-0377
Is Sole Proprietor?:No
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH031417183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist