Provider Demographics
NPI:1912611542
Name:ELLIS, STEPHANIE GRAINGER (RPH)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:GRAINGER
Last Name:ELLIS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8013 REUNION RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28411-9271
Mailing Address - Country:US
Mailing Address - Phone:910-617-0766
Mailing Address - Fax:
Practice Address - Street 1:4459 TARHEEL DR
Practice Address - Street 2:
Practice Address - City:PINK HILL
Practice Address - State:NC
Practice Address - Zip Code:28572-9649
Practice Address - Country:US
Practice Address - Phone:252-568-9945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC130321835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric