Provider Demographics
NPI:1992539357
Name:ELLIS, KAITLYN RAE (PHARMD)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:RAE
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 1:1148 HAWKINS RD
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-3790
Mailing Address - Country:US
Mailing Address - Phone:314-775-3117
Mailing Address - Fax:
Practice Address - Street 1:400 S TRUMAN BLVD
Practice Address - Street 2:
Practice Address - City:CRYSTAL CITY
Practice Address - State:MO
Practice Address - Zip Code:63019-1726
Practice Address - Country:US
Practice Address - Phone:636-937-3178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024033223183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist