Healthcare Provider Details

I. General information

NPI: 1245935659
Provider Name (Legal Business Name): ELLIE THOMPSON PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2023
Last Update Date: 04/04/2023
Certification Date: 04/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 AIRPARK DR
MYRTLE BEACH SC
29577-1412
US

IV. Provider business mailing address

5064 WAVERING PLACE LOOP
MYRTLE BEACH SC
29579-3416
US

V. Phone/Fax

Practice location:
  • Phone: 843-477-0177
  • Fax:
Mailing address:
  • Phone: 308-550-1437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number17170
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number43526
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: