Provider Demographics
NPI:1952401424
Name:ELLIS, PAMELA SUE (RPH)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:SUE
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 1:4136 BITTERSWEET LANE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-7403
Mailing Address - Country:US
Mailing Address - Phone:317-881-1195
Mailing Address - Fax:
Practice Address - Street 1:VA MEDICAL CENTER
Practice Address - Street 2:1481 WEST 10TH STREET
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2803
Practice Address - Country:US
Practice Address - Phone:317-554-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26016922A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist