Provider Demographics
NPI:1780247288
Name:ELY EXTENDED CARE INC.
Entity type:Organization
Organization Name:ELY EXTENDED CARE INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:LASHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-479-0340
Mailing Address - Street 1:PO BOX 187
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42142-0187
Mailing Address - Country:US
Mailing Address - Phone:270-479-0340
Mailing Address - Fax:270-629-5769
Practice Address - Street 1:109 MORAN ST
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-1632
Practice Address - Country:US
Practice Address - Phone:270-479-0340
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-19
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy