Provider Demographics
NPI:1134744428
Name:SHIPLEY, ELISA
Entity type:Individual
Prefix:
First Name:ELISA
Middle Name:
Last Name:SHIPLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELISA
Other - Middle Name:
Other - Last Name:ALFARO-MALAVE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1168 WAGNER AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-7840
Mailing Address - Country:US
Mailing Address - Phone:954-952-2722
Mailing Address - Fax:
Practice Address - Street 1:3541 RANDOLPH RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1082
Practice Address - Country:US
Practice Address - Phone:704-365-0707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-11
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC26643183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist