Provider Demographics
NPI:1386337723
Name:PRICE, JEFFREY ELLIS (PHARMACIST)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ELLIS
Last Name:PRICE
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53561 FOREST LAKES DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:IN
Mailing Address - Zip Code:46540-8970
Mailing Address - Country:US
Mailing Address - Phone:574-536-3581
Mailing Address - Fax:
Practice Address - Street 1:2304 LINCOLNWAY E
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-6421
Practice Address - Country:US
Practice Address - Phone:574-534-4483
Practice Address - Fax:574-533-7248
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26016099A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist