Provider Demographics
NPI:1073060455
Name:POMERENKE, KELLI
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:POMERENKE
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 1:10650 MARMON ST NE
Mailing Address - Street 2:
Mailing Address - City:CIRCLE PINES
Mailing Address - State:MN
Mailing Address - Zip Code:55014-1547
Mailing Address - Country:US
Mailing Address - Phone:612-384-4411
Mailing Address - Fax:
Practice Address - Street 1:550 VANDALIA ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1833
Practice Address - Country:US
Practice Address - Phone:844-532-3546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-02
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN728552183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician