Provider Demographics
NPI:1952499238
Name:ELLIS, GINGER R
Entity Type:Individual
Prefix:MS
First Name:GINGER
Middle Name:R
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 1:2460 HAMILTON PARC LN
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-6201
Mailing Address - Country:US
Mailing Address - Phone:757-635-0049
Mailing Address - Fax:
Practice Address - Street 1:1200 NORTHSIDE FORSYTH DR
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-7659
Practice Address - Country:US
Practice Address - Phone:770-844-3290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH023388183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist