Healthcare Provider Details

I. General information

NPI: 1750837001
Provider Name (Legal Business Name): ELLEN LEROSE PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2016
Last Update Date: 08/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601-B RICHMOND ROAD
WILLIAMSBURG VA
23185
US

IV. Provider business mailing address

5601-B RICHMOND ROAD
WILLIAMSBURG VA
23185
US

V. Phone/Fax

Practice location:
  • Phone: 757-565-6407
  • Fax: 757-565-6443
Mailing address:
  • Phone: 757-565-6407
  • Fax: 757-565-6443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202215074
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: