Provider Demographics
NPI:1871141473
Name:ELLSPERMAN, MICHAEL WAYNE (RPH)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WAYNE
Last Name:ELLSPERMAN
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 1:609 N SAINT JOSEPH AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47712-5554
Mailing Address - Country:US
Mailing Address - Phone:812-424-3894
Mailing Address - Fax:
Practice Address - Street 1:609 N SAINT JOSEPH AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47712-5554
Practice Address - Country:US
Practice Address - Phone:812-424-3894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26013763A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist