Provider Demographics
NPI:1871919845
Name:ELLIS, MICHELL R (PHARMD)
Entity type:Individual
Prefix:
First Name:MICHELL
Middle Name:R
Last Name:ELLIS
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 1:2 GOOD SAMARITAN WAY
Mailing Address - Street 2:SUITE 120
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2408
Mailing Address - Country:US
Mailing Address - Phone:618-899-4999
Mailing Address - Fax:618-899-4799
Practice Address - Street 1:2 GOOD SAMARITAN WAY
Practice Address - Street 2:SUITE 120
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2408
Practice Address - Country:US
Practice Address - Phone:618-899-4999
Practice Address - Fax:618-899-4799
Is Sole Proprietor?:No
Enumeration Date:2014-03-13
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.292773183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist