Provider Demographics
NPI:1932423159
Name:ELLYASON, LYUDMILA
Entity Type:Individual
Prefix:MISS
First Name:LYUDMILA
Middle Name:
Last Name:ELLYASON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6565 WETHEROLE ST APT 4B
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-4777
Mailing Address - Country:US
Mailing Address - Phone:718-997-0765
Mailing Address - Fax:
Practice Address - Street 1:6565 WETHEROLE ST APT 4B
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-4777
Practice Address - Country:US
Practice Address - Phone:718-997-0765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-17
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050142-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist