Provider Demographics
NPI:1457616328
Name:ELIAS, THERESA ANN
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:ANN
Last Name:ELIAS
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 1:11750 COMMERCIAL DR
Mailing Address - Street 2:T-1350
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-2903
Mailing Address - Country:US
Mailing Address - Phone:317-845-4962
Mailing Address - Fax:
Practice Address - Street 1:11750 COMMERCIAL DR
Practice Address - Street 2:T-1350
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-2903
Practice Address - Country:US
Practice Address - Phone:317-845-4962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-06
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26016491A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN26016491AMedicaid