Healthcare Provider Details

I. General information

NPI: 1659768034
Provider Name (Legal Business Name): MARK ALDOR ELLINGSON R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2015
Last Update Date: 04/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 MULLAN AVENUE BOX 2170
OSBURN ID
83849
US

IV. Provider business mailing address

805 MULLAN AVENUE
OSBURN ID
83849
US

V. Phone/Fax

Practice location:
  • Phone: 208-752-1028
  • Fax:
Mailing address:
  • Phone: 208-752-1028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP7037
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: