Healthcare Provider Details

I. General information

NPI: 1871417170
Provider Name (Legal Business Name): JEREMIAH ELI ELLISON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2026
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2715 E BATTLEFIELD RD
SPRINGFIELD MO
65804-3981
US

IV. Provider business mailing address

2439 STATE HIGHWAY T
OLDFIELD MO
65720-9220
US

V. Phone/Fax

Practice location:
  • Phone: 417-888-0298
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2026036367
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: