Healthcare Provider Details

I. General information

NPI: 1285242164
Provider Name (Legal Business Name): DR. JOHN A ELLIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2020
Last Update Date: 07/16/2020
Certification Date: 07/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 N FRASER ST
GEORGETOWN SC
29440-3353
US

IV. Provider business mailing address

162 MIDWAY DR
PAWLEYS ISLAND SC
29585-5294
US

V. Phone/Fax

Practice location:
  • Phone: 843-545-9292
  • Fax:
Mailing address:
  • Phone: 843-457-4773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number10241
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: