Provider Demographics
NPI:1366712788
Name:EBERT, ELIZABETH
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:
Last Name:EBERT
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 1:5725 ENDICOTT AVE SW
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:MN
Mailing Address - Zip Code:55390-8624
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:121 DEPOT DR
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1874
Practice Address - Country:US
Practice Address - Phone:952-442-2146
Practice Address - Fax:952-442-5643
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-02
Last Update Date:2012-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN118563183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist