Provider Demographics
NPI:1447852363
Name:ELLYSON, KELLIE RAE (PHARMD)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:RAE
Last Name:ELLYSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 YIOTIS WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-6660
Mailing Address - Country:US
Mailing Address - Phone:660-346-0322
Mailing Address - Fax:
Practice Address - Street 1:405 E NIFONG BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-3708
Practice Address - Country:US
Practice Address - Phone:573-442-8616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020020031183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist