Provider Demographics
NPI:1124018197
Name:REYES-GROTE, ELLI (RPH)
Entity type:Individual
Prefix:
First Name:ELLI
Middle Name:
Last Name:REYES-GROTE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 868
Mailing Address - Street 2:
Mailing Address - City:MATAWAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07747-0868
Mailing Address - Country:US
Mailing Address - Phone:732-441-1006
Mailing Address - Fax:
Practice Address - Street 1:1075 STEPHENSON AVE
Practice Address - Street 2:
Practice Address - City:FORT MONMOUTH
Practice Address - State:NJ
Practice Address - Zip Code:07703
Practice Address - Country:US
Practice Address - Phone:732-532-2551
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI3524183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist