Provider Demographics
NPI:1033433537
Name:GINGRASS, KELLY ANGELA (RPH)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANGELA
Last Name:GINGRASS
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 1:1300 WALKER ST
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-6604
Mailing Address - Country:US
Mailing Address - Phone:906-774-6864
Mailing Address - Fax:
Practice Address - Street 1:1810 S STEPHENSON AVE
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-3615
Practice Address - Country:US
Practice Address - Phone:906-779-2163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-26
Last Update Date:2010-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302032013183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist