Provider Demographics
NPI:1023392628
Name:MESSMER, KELLEY MARIE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:KELLEY
Middle Name:MARIE
Last Name:MESSMER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5425 N PROSPECT RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5274
Mailing Address - Country:US
Mailing Address - Phone:309-688-9081
Mailing Address - Fax:
Practice Address - Street 1:2106 W TOWNLINE RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-1547
Practice Address - Country:US
Practice Address - Phone:309-692-2826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-01
Last Update Date:2011-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051038751183500000X
MO043139183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist