Provider Demographics
NPI:1134203052
Name:ELLIS, STACEY A (RPH)
Entity type:Individual
Prefix:DR
First Name:STACEY
Middle Name:A
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 1:7665 JENNIFER LN
Mailing Address - Street 2:
Mailing Address - City:BROWNSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:46112-8596
Mailing Address - Country:US
Mailing Address - Phone:317-858-2345
Mailing Address - Fax:317-858-2348
Practice Address - Street 1:843 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BROWNSBURG
Practice Address - State:IN
Practice Address - Zip Code:46112-1457
Practice Address - Country:US
Practice Address - Phone:317-858-2345
Practice Address - Fax:317-858-2348
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26020400A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist