Individual
MARIA LORENA ELLISON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
1600 WILDCAT DR, PORTLAND, TX 78374-2816
(351) 643-1514
Mailing address
1600 WILDCAT DR, PORTLAND, TX 78374-2816
(461) 643-1514
Taxonomy
Speciality
Code
Description
License number
State
183700000X
Pharmacy Technician
Primary
288892
TX
Other
Enumeration date
04/14/2021
Last updated
04/14/2021
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