Provider Demographics
NPI:1013284355
Name:ELLEGATE, GRACE H
Entity Type:Individual
Prefix:MS
First Name:GRACE
Middle Name:H
Last Name:ELLEGATE
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 1:7 LINN AVENUE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-4311
Mailing Address - Country:US
Mailing Address - Phone:315-440-2681
Mailing Address - Fax:
Practice Address - Street 1:135 STATE ST
Practice Address - Street 2:C/O PHARMACY DEPARTMENT
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13024-9001
Practice Address - Country:US
Practice Address - Phone:315-253-8401
Practice Address - Fax:315-255-1371
Is Sole Proprietor?:No
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0353731183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist