Basic Information
| Provider Information | |||||||||
| NPI: | 1629387378 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLWOOD | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARM.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 643 VIA FIRENZE | ||||||||
| Address2: | |||||||||
| City: | CATHEDRAL CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922344184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072068172 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 36000 DARNALL LOOP | ||||||||
| Address2: | CARL R. DARNALL ARMY MEDICAL CENTER | ||||||||
| City: | FORT HOOD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542888025 | ||||||||
| FaxNumber: | 2542867326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2010 | ||||||||
| LastUpdateDate: | 09/29/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | RP00007424 | NM | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.