Provider Demographics
NPI:1285312173
Name:ELLENBECKER, SIERRAH
Entity type:Individual
Prefix:
First Name:SIERRAH
Middle Name:
Last Name:ELLENBECKER
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 1:760 PRENTICE ST
Mailing Address - Street 2:
Mailing Address - City:GRANITE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56241-1541
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:760 PRENTICE ST
Practice Address - Street 2:
Practice Address - City:GRANITE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56241-1541
Practice Address - Country:US
Practice Address - Phone:320-564-2339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN126076183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist