Provider Demographics
NPI:1871249490
Name:ELLIS, ANN ELIZABETH (RPH)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:ELIZABETH
Last Name:ELLIS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:284 S BROADMOOR BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45504-1158
Mailing Address - Country:US
Mailing Address - Phone:937-207-9095
Mailing Address - Fax:
Practice Address - Street 1:401 W NORTH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504-2607
Practice Address - Country:US
Practice Address - Phone:937-324-5796
Practice Address - Fax:937-322-4516
Is Sole Proprietor?:No
Enumeration Date:2022-02-22
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03217762183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1023028701OtherNPI