Provider Demographics
NPI:1093024721
Name:EVANS, KELLY L (PHARMD)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:L
Last Name:EVANS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:L
Other - Last Name:LANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:5048 W MCMILLAN RD
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49445-8687
Mailing Address - Country:US
Mailing Address - Phone:616-516-2106
Mailing Address - Fax:
Practice Address - Street 1:1675 LEAHY ST
Practice Address - Street 2:STUITE 111
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-5500
Practice Address - Country:US
Practice Address - Phone:231-728-5888
Practice Address - Fax:231-728-4093
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-29
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302036260183500000X
MI53010052763336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy