Provider Demographics
NPI:1114730462
Name:ELLIS, TIFFANY
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14906 KELLY DR
Mailing Address - Street 2:
Mailing Address - City:SMITHVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64089-8405
Mailing Address - Country:US
Mailing Address - Phone:518-810-2941
Mailing Address - Fax:
Practice Address - Street 1:15700 N US HIGHWAY 169
Practice Address - Street 2:
Practice Address - City:SMITHVILLE
Practice Address - State:MO
Practice Address - Zip Code:64089-9314
Practice Address - Country:US
Practice Address - Phone:816-532-6140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-30
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020027251183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist