Provider Demographics
NPI:1447371935
Name:ELLIOTT, MICHAEL DAVID (RPH)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DAVID
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OH
Mailing Address - Zip Code:45810-1112
Mailing Address - Country:US
Mailing Address - Phone:419-634-9220
Mailing Address - Fax:419-634-0893
Practice Address - Street 1:610 S. MAIN ST.
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OH
Practice Address - Zip Code:45810
Practice Address - Country:US
Practice Address - Phone:419-634-0888
Practice Address - Fax:419-634-0893
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-3-14589183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist