Provider Demographics
NPI:1932709151
Name:ELLERMAN, CHARLES
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:ELLERMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1803 S LOST RD
Mailing Address - Street 2:
Mailing Address - City:MONROE CITY
Mailing Address - State:IN
Mailing Address - Zip Code:47557-7315
Mailing Address - Country:US
Mailing Address - Phone:812-887-4259
Mailing Address - Fax:
Practice Address - Street 1:2610 W HAVEN RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62439-3345
Practice Address - Country:US
Practice Address - Phone:618-943-5515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.293163183500000X
IN26022434A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist