Healthcare Provider Details

I. General information

NPI: 1962431866
Provider Name (Legal Business Name): MELISSA KATHLEEN ELLIS PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELISSA KATHLEEN EGAN PHARM.D.

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3350 LA JOLLA VILLAGE DR PHARMACY DEPT (119)
SAN DIEGO CA
92161-0002
US

IV. Provider business mailing address

3350 LA JOLLA VILLAGE DR PHARMACY DEPT 119
SAN DIEGO CA
92161-1050
US

V. Phone/Fax

Practice location:
  • Phone: 858-642-1607
  • Fax: 858-514-1664
Mailing address:
  • Phone: 858-552-8585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number50504
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: