Provider Demographics
NPI:1861138752
Name:ELLIS-OTOO, FATIMA
Entity type:Individual
Prefix:
First Name:FATIMA
Middle Name:
Last Name:ELLIS-OTOO
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 1:8035 HIGHWAY 6 STE 130
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-2818
Mailing Address - Country:US
Mailing Address - Phone:281-915-2166
Mailing Address - Fax:281-915-2164
Practice Address - Street 1:8035 HIGHWAY 6 STE 130
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-2818
Practice Address - Country:US
Practice Address - Phone:281-915-2166
Practice Address - Fax:281-915-2164
Is Sole Proprietor?:No
Enumeration Date:2022-05-12
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX52564183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist