Provider Demographics
NPI:1679133920
Name:ELLSWORTH, CHRISTA MARIE (PHARMD)
Entity type:Individual
Prefix:
First Name:CHRISTA
Middle Name:MARIE
Last Name:ELLSWORTH
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 1:1919 GREENLEAF ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92706-2529
Mailing Address - Country:US
Mailing Address - Phone:330-354-1642
Mailing Address - Fax:
Practice Address - Street 1:200 W CENTER STREET PROMENADE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-3960
Practice Address - Country:US
Practice Address - Phone:330-354-1642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-19
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA70444183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist