Healthcare Provider Details

I. General information

NPI: 1871249490
Provider Name (Legal Business Name): ANN ELIZABETH ELLIS RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2022
Last Update Date: 02/22/2022
Certification Date: 02/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 W NORTH ST
SPRINGFIELD OH
45504-2607
US

IV. Provider business mailing address

284 S BROADMOOR BLVD
SPRINGFIELD OH
45504-1158
US

V. Phone/Fax

Practice location:
  • Phone: 937-324-5796
  • Fax: 937-322-4516
Mailing address:
  • Phone: 937-207-9095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03217762
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: