MEDICARE: ROBERT ALLEN ELLSWORTH R.P.

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	8796	NE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8796	OTHER	NE	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1821140989
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT ALLEN ELLSWORTH R.P.

Provider Business Mailing Address
First Line	:	3930 D RD
Second Line	:
City	:	BELLWOOD
State	:	NE
Zip	:	68624-2491
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2759 33RD AVE
Second Line	:
City	:	COLUMBUS
State	:	NE
Zip	:	68601-2327
Country	:	US
Telephone Number	:	402-564-2883
Fax Number	:	402-563-1272

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

Provider Enumeration Date	:	01/17/2007
Last Update Date	:	07/08/2007

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