Provider Demographics
NPI:1679381578
Name:WIRAWAN, ELLEN (PHARMD)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:WIRAWAN
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 1:100 GROVE LN
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19711-5481
Mailing Address - Country:US
Mailing Address - Phone:302-286-0415
Mailing Address - Fax:
Practice Address - Street 1:100 GROVE LN
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19711-5481
Practice Address - Country:US
Practice Address - Phone:302-286-0415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-23
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEA1-0016077183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist