Provider Demographics
NPI:1871901264
Name:WILLIAM LEON ELLIS JR
Entity type:Organization
Organization Name:WILLIAM LEON ELLIS JR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:828-754-2184
Mailing Address - Street 1:935 BLOWING ROCK BLVD
Mailing Address - Street 2:
Mailing Address - City:LENOIR
Mailing Address - State:NC
Mailing Address - Zip Code:28645-3785
Mailing Address - Country:US
Mailing Address - Phone:828-754-2184
Mailing Address - Fax:828-754-2462
Practice Address - Street 1:935 BLOWING ROCK BLVD
Practice Address - Street 2:
Practice Address - City:LENOIR
Practice Address - State:NC
Practice Address - Zip Code:28645-3785
Practice Address - Country:US
Practice Address - Phone:828-754-2184
Practice Address - Fax:828-754-2462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-29
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5920333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0145375Medicaid