Provider Demographics
NPI:1093047698
Name:MARLER, KELLY LOUIS (RPH)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:LOUIS
Last Name:MARLER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 PULLIAM AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62258-5010
Mailing Address - Country:US
Mailing Address - Phone:618-677-2296
Mailing Address - Fax:
Practice Address - Street 1:6525 N ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-2001
Practice Address - Country:US
Practice Address - Phone:618-397-2091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-05
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-037464183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist