Provider Demographics
NPI:1013385020
Name:KELLY, KAREN
Entity Type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 GUERNSEY LN
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29306-6402
Mailing Address - Country:US
Mailing Address - Phone:774-722-2682
Mailing Address - Fax:
Practice Address - Street 1:101 LOCUST ST
Practice Address - Street 2:
Practice Address - City:LYMAN
Practice Address - State:SC
Practice Address - Zip Code:29365-1503
Practice Address - Country:US
Practice Address - Phone:864-439-1040
Practice Address - Fax:864-949-0461
Is Sole Proprietor?:No
Enumeration Date:2015-09-08
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC35977183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist