Provider Demographics
NPI:1023120037
Name:JOSEPH R ELLIS
Entity type:Organization
Organization Name:JOSEPH R ELLIS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:R
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-363-0750
Mailing Address - Street 1:4770 KNIGHT ARNOLD RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38118-3201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4770 KNIGHT ARNOLD RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38118-3201
Practice Address - Country:US
Practice Address - Phone:901-363-0750
Practice Address - Fax:901-363-0782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2151333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4426626OtherOTHER ID NUMBER-COMMERCIAL NUMBER
TN870023576OtherMEDICARE (RR)
TN870023576OtherMEDICARE (RR)
TN0642480001Medicare NSC
TN3913653Medicare PIN