Provider Demographics
NPI:1487066676
Name:ELLIS, GERALD
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:GERALD
Other - Middle Name:
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:R PH
Mailing Address - Street 1:6206 TWISTED OAK CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-2649
Mailing Address - Country:US
Mailing Address - Phone:260-402-5429
Mailing Address - Fax:
Practice Address - Street 1:10301 E STATE ROAD 37
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46835-9591
Practice Address - Country:US
Practice Address - Phone:260-492-1333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-22
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26023966A1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy