Provider Demographics
NPI:1053907063
Name:JERRELL, ELIZABETH (PHARMD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:JERRELL
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12540 WOODVILLE RD
Mailing Address - Street 2:
Mailing Address - City:KEVIL
Mailing Address - State:KY
Mailing Address - Zip Code:42053-9337
Mailing Address - Country:US
Mailing Address - Phone:270-994-4604
Mailing Address - Fax:
Practice Address - Street 1:3001 LONE OAK RD
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-5721
Practice Address - Country:US
Practice Address - Phone:270-994-4604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY021765183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty