Provider Demographics
NPI:1073986238
Name:KOSTIC, KELLY (PHARMD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KOSTIC
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 W 40TH ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21211-2120
Mailing Address - Country:US
Mailing Address - Phone:410-467-3343
Mailing Address - Fax:
Practice Address - Street 1:711 W 40TH ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211-2120
Practice Address - Country:US
Practice Address - Phone:410-467-3343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23422183500000X
VA0202214208183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist