Provider Demographics
NPI:1083684799
Name:BOLESTA, KELLY M (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:M
Last Name:BOLESTA
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 1:1000 E MOUNTAIN BLVD # MC34-06
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18711-0001
Mailing Address - Country:US
Mailing Address - Phone:570-808-7706
Mailing Address - Fax:570-808-6433
Practice Address - Street 1:1000 E MOUNTAIN BLVD # MC34-06
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18711-0001
Practice Address - Country:US
Practice Address - Phone:570-808-7706
Practice Address - Fax:570-808-6433
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP4380811835P1200X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy