Provider Demographics
NPI:1144652629
Name:KELLISON, ERIK DANIEL (PHARMD)
Entity type:Individual
Prefix:DR
First Name:ERIK
Middle Name:DANIEL
Last Name:KELLISON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1802 YAKIMA AVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4499
Mailing Address - Country:US
Mailing Address - Phone:253-627-1244
Mailing Address - Fax:253-779-6221
Practice Address - Street 1:1802 YAKIMA AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4499
Practice Address - Country:US
Practice Address - Phone:253-627-1244
Practice Address - Fax:253-779-6221
Is Sole Proprietor?:No
Enumeration Date:2013-08-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60389489183500000X
COPHA.0019956183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPH60389489OtherWA STATE PHARMACIST LICENSE #
WAPH60389489OtherWA STATE PHARMACIST LICENSE #