Provider Demographics
NPI:1881748754
Name:ELLEYS PHARMACY
Entity type:Organization
Organization Name:ELLEYS PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:ELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:816-650-5611
Mailing Address - Street 1:306 S HUDSON
Mailing Address - Street 2:BOX 108
Mailing Address - City:BUCKNER
Mailing Address - State:MO
Mailing Address - Zip Code:64016-0108
Mailing Address - Country:US
Mailing Address - Phone:816-650-5611
Mailing Address - Fax:816-650-5611
Practice Address - Street 1:306 S HUDSON
Practice Address - Street 2:
Practice Address - City:BUCKNER
Practice Address - State:MO
Practice Address - Zip Code:64016-0108
Practice Address - Country:US
Practice Address - Phone:816-650-5611
Practice Address - Fax:816-650-5611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0039963336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2605105Medicare UPIN