Provider Demographics
NPI:1780053884
Name:ELLIS, KENDRA (PHARMD)
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 310384
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33680-0384
Mailing Address - Country:US
Mailing Address - Phone:813-770-3472
Mailing Address - Fax:
Practice Address - Street 1:2290 PREMIER ROW
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-6212
Practice Address - Country:US
Practice Address - Phone:813-770-3472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-18
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS478181835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist