Provider Demographics
NPI:1477281830
Name:ELLICOTT, KENZIE SHAY (PHARMD)
Entity type:Individual
Prefix:
First Name:KENZIE
Middle Name:SHAY
Last Name:ELLICOTT
Suffix:
Gender:
Credentials:PHARMD
Other - Prefix:
Other - First Name:KENZIE
Other - Middle Name:SHAY
Other - Last Name:TYINK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:162 E 56TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWAYGO
Mailing Address - State:MI
Mailing Address - Zip Code:49337-9048
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:226 W RIVER VALLEY DR
Practice Address - Street 2:
Practice Address - City:NEWAYGO
Practice Address - State:MI
Practice Address - Zip Code:49337-8972
Practice Address - Country:US
Practice Address - Phone:231-652-6914
Practice Address - Fax:231-652-2650
Is Sole Proprietor?:No
Enumeration Date:2022-08-12
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302414374183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist