Provider Demographics
NPI:1538771860
Name:ELLIS, TIANIA MELESIA
Entity type:Individual
Prefix:
First Name:TIANIA
Middle Name:MELESIA
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:637 HOBOKEN RD
Mailing Address - Street 2:
Mailing Address - City:CARLSTADT
Mailing Address - State:NJ
Mailing Address - Zip Code:07072-1143
Mailing Address - Country:US
Mailing Address - Phone:201-842-0916
Mailing Address - Fax:201-842-0706
Practice Address - Street 1:637 HOBOKEN RD
Practice Address - Street 2:
Practice Address - City:CARLSTADT
Practice Address - State:NJ
Practice Address - Zip Code:07072-1143
Practice Address - Country:US
Practice Address - Phone:201-842-0916
Practice Address - Fax:201-842-0706
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03836300183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist