Provider Demographics
NPI:1093156218
Name:HOLCOMB, KELLY ANN (PHARMD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:HOLCOMB
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 1:338 E SOUTH TEMPLE
Mailing Address - Street 2:APT 514
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-1202
Mailing Address - Country:US
Mailing Address - Phone:205-587-4792
Mailing Address - Fax:
Practice Address - Street 1:338 E SOUTH TEMPLE
Practice Address - Street 2:APT 514
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-1202
Practice Address - Country:US
Practice Address - Phone:205-587-4792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-16
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT83327541701183500000X
MSE-12608183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist