MEDICARE: ELLISON BROWN JR.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	41588	TN
2	183500000X	Pharmacist	E-15036	MS

General Provider Information

NPI Number	:	1689279697
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLISON BROWN JR.

Provider Business Mailing Address
First Line	:	7363 GOODMAN RD
Second Line	:
City	:	OLIVE BRANCH
State	:	MS
Zip	:	38654-1906
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7363 GOODMAN RD
Second Line	:
City	:	OLIVE BRANCH
State	:	MS
Zip	:	38654-1906
Country	:	US
Telephone Number	:	662-890-7555
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2020
Last Update Date	:	12/07/2020

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