Provider Demographics
NPI:1982756078
Name:ELLIS, DIANE LYNN (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:LYNN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15007 MEADOWLAKE ST.
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:FL
Mailing Address - Zip Code:33556-3156
Mailing Address - Country:US
Mailing Address - Phone:813-920-3253
Mailing Address - Fax:
Practice Address - Street 1:8415 BAYSHORE BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33621-1607
Practice Address - Country:US
Practice Address - Phone:813-827-9310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS 25778183500000X
GARPH015767183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist