Provider Demographics
NPI:1992334304
Name:ELLIS, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:923 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:WINTERSET
Mailing Address - State:IA
Mailing Address - Zip Code:50273-1231
Mailing Address - Country:US
Mailing Address - Phone:515-462-4299
Mailing Address - Fax:515-462-6739
Practice Address - Street 1:923 N 1ST ST
Practice Address - Street 2:
Practice Address - City:WINTERSET
Practice Address - State:IA
Practice Address - Zip Code:50273-1231
Practice Address - Country:US
Practice Address - Phone:515-971-4492
Practice Address - Fax:515-462-6739
Is Sole Proprietor?:No
Enumeration Date:2020-04-07
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA21089183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist