Provider Demographics
NPI:1720496920
Name:ELLSWORTH, BRIAN KEITH JR (PHARMD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:KEITH
Last Name:ELLSWORTH
Suffix:JR
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:681 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230-2215
Mailing Address - Country:US
Mailing Address - Phone:410-459-1016
Mailing Address - Fax:401-216-3435
Practice Address - Street 1:1000 S CHARLES ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21230-4046
Practice Address - Country:US
Practice Address - Phone:410-752-9087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-31
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19750183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist