Provider Demographics
NPI:1992147219
Name:ELLIS, STEPHANIE RACHEL (PHARMD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:RACHEL
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1257 BECKMAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-6901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:318 MALL BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-4700
Practice Address - Country:US
Practice Address - Phone:912-200-9165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-28
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH027319183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist