Healthcare Provider Details

I. General information

NPI: 1306449186
Provider Name (Legal Business Name): KURT ELLISON PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2020
Last Update Date: 06/17/2021
Certification Date: 06/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14355 W NEWBERRY RD
NEWBERRY FL
32669-2848
US

IV. Provider business mailing address

14355 W NEWBERRY RD
NEWBERRY FL
32669-2848
US

V. Phone/Fax

Practice location:
  • Phone: 352-331-4639
  • Fax: 352-331-4208
Mailing address:
  • Phone: 352-682-0767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS35831
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: