Provider Demographics
NPI:1871876953
Name:ELLISON, MARY MARGARET (RPH)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:MARGARET
Last Name:ELLISON
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 1:400 MASON RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63304-7283
Mailing Address - Country:US
Mailing Address - Phone:636-447-5977
Mailing Address - Fax:
Practice Address - Street 1:1490 MEXICO LOOP RD E
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-6015
Practice Address - Country:US
Practice Address - Phone:636-978-1602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-24
Last Update Date:2011-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO042428183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1922013176Medicaid