Provider Demographics
NPI:1902108319
Name:CROCKETT, ELLA SUE
Entity type:Individual
Prefix:MRS
First Name:ELLA
Middle Name:SUE
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:ELLA
Other - Middle Name:SUE
Other - Last Name:ADAMS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHARMD
Mailing Address - Street 1:6610 TIDWELL RD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77016-4824
Mailing Address - Country:US
Mailing Address - Phone:713-633-2230
Mailing Address - Fax:
Practice Address - Street 1:6610 TIDWELL RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77016-4824
Practice Address - Country:US
Practice Address - Phone:713-633-2230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-18
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX44899183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist