Provider Demographics
NPI:1821140989
Name:ELLSWORTH, ROBERT ALLEN (RP)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:ALLEN
Last Name:ELLSWORTH
Suffix:
Gender:M
Credentials:RP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3930 D RD
Mailing Address - Street 2:
Mailing Address - City:BELLWOOD
Mailing Address - State:NE
Mailing Address - Zip Code:68624-2491
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2759 33RD AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:NE
Practice Address - Zip Code:68601-2327
Practice Address - Country:US
Practice Address - Phone:402-564-2883
Practice Address - Fax:402-563-1272
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE8796183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE8796OtherSTATE LICENSE NUMBER