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Individual

MR. MARK ALDOR ELLINGSON

Active
Sole proprietor
No

Provider details

NPI number
Gender
Man
Credential
R.PH.

Contact information

Practice address
805 MULLAN AVENUE, BOX 2170, OSBURN, ID 83849
(208) 752-1028
Mailing address
805 MULLAN AVENUE, OSBURN, ID 83849
(208) 752-1028

Taxonomy

Speciality
Code
Description
License number
State
183500000X
Pharmacist
Primary
P7037
ID

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
002450000
ID
Enumeration date
04/23/2015
Last updated
04/23/2015
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