Basic Information
| Provider Information | |||||||||
| NPI: | 1083170153 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLISON | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | RUSSELL | ||||||||
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| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10024 W 118TH TER APT 8 | ||||||||
| Address2: | |||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662103193 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3411 S NOLAND RD | ||||||||
| Address2: | |||||||||
| City: | INDEPENDENCE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640551319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162520094 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2019 | ||||||||
| LastUpdateDate: | 05/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 1-106867 | KS | N | Pharmacy Service Providers | Pharmacist | 183500000X | 2019014830 | MO | N | Pharmacy Service Providers | Pharmacist | 183500000X | 18552-40 | WI | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.