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General NPI Number Information
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NPI Number | 1932709151
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Entity Type | Individual
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Provider Name | CHARLES ELLERMAN
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Gender | Male
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Dates
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Enumeration Date | 10/27/2020
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Last Update Date | 10/27/2020
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Provider Practice Location Address
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Address Line | 2610 W HAVEN RD
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City | LAWRENCEVILLE
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State | IL
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Zip | 62439-3345
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Country | US
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Telephone | 618-943-5515
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Fax |
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Provider Business Mailing Address
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Address Line | 1803 S LOST RD
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City | MONROE CITY
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State | IN
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Zip | 47557-7315
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Country | US
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Telephone | 812-887-4259
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 051.293163
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 26022434A
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License Number State | IN
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