Provider Demographics
NPI:1619011954
Name:ENNIS, MITCHELL LEWIS I (RPH)
Entity type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:LEWIS
Last Name:ENNIS
Suffix:I
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 CANTERBURY RD
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35223-1909
Mailing Address - Country:US
Mailing Address - Phone:205-871-5972
Mailing Address - Fax:
Practice Address - Street 1:4901 GARY AVE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:AL
Practice Address - Zip Code:35064-1348
Practice Address - Country:US
Practice Address - Phone:205-785-4343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6673183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist