Provider Demographics
NPI:1245441633
Name:ELLIS, MILLIE ANN
Entity type:Individual
Prefix:MRS
First Name:MILLIE
Middle Name:ANN
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 1:210 E MAX DR
Mailing Address - Street 2:
Mailing Address - City:PENNVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47369
Mailing Address - Country:US
Mailing Address - Phone:260-731-5761
Mailing Address - Fax:
Practice Address - Street 1:222 N WAYNE ST
Practice Address - Street 2:WARREN PHARMACY
Practice Address - City:WARREN
Practice Address - State:IN
Practice Address - Zip Code:46792
Practice Address - Country:US
Practice Address - Phone:260-375-2135
Practice Address - Fax:260-375-7030
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN67000393A183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician