Provider Demographics
NPI:1902924475
Name:ELLISON, LARRY W (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:W
Last Name:ELLISON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:187 LAKE FOREST DR.
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503
Mailing Address - Country:US
Mailing Address - Phone:606-875-3322
Mailing Address - Fax:
Practice Address - Street 1:1250 S HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501-3525
Practice Address - Country:US
Practice Address - Phone:606-676-0485
Practice Address - Fax:160-667-6962
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY013346183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist