Basic Information
| Provider Information | |||||||||
| NPI: | 1912517368 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIOTT | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | |||||||||
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| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11 OVERLOOK DR | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 263301021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043650921 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 EMILY DR | ||||||||
| Address2: | |||||||||
| City: | CLARKSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 263015500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3049186056 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2020 | ||||||||
| LastUpdateDate: | 07/31/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | RPH0007700 | WV | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | RP0007700 | 01 | WV | BOARD OF PHARMACY | OTHER |