Provider Demographics
NPI:1003509134
Name:KELLY, JOHN WALTER
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WALTER
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:828 N BROADWAY APT 450
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80203-2789
Mailing Address - Country:US
Mailing Address - Phone:317-690-7901
Mailing Address - Fax:
Practice Address - Street 1:120 N BROADWAY
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80203-3917
Practice Address - Country:US
Practice Address - Phone:303-722-0771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-02
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COIN.0002009559183500000X, 183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No183700000XPharmacy Service ProvidersPharmacy Technician