Provider Demographics
NPI:1699716845
Name:ELLIS, JEFFRY RICHARD (RPH)
Entity type:Individual
Prefix:MR
First Name:JEFFRY
Middle Name:RICHARD
Last Name:ELLIS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1175 LADY BIRD DR
Mailing Address - Street 2:
Mailing Address - City:SOMONAUK
Mailing Address - State:IL
Mailing Address - Zip Code:60552-9627
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:142 INDIAN SPRINGS DR
Practice Address - Street 2:
Practice Address - City:SANDWICH
Practice Address - State:IL
Practice Address - Zip Code:60548-1902
Practice Address - Country:US
Practice Address - Phone:815-786-2300
Practice Address - Fax:815-786-2311
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.030682183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist