Provider Demographics
NPI:1093384703
Name:KELLEY, HEATHER (PHARMD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:KELLEY
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 1:601 12TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-5324
Mailing Address - Country:US
Mailing Address - Phone:405-579-5208
Mailing Address - Fax:405-579-5210
Practice Address - Street 1:601 12TH AVE NE
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-5324
Practice Address - Country:US
Practice Address - Phone:405-579-5208
Practice Address - Fax:405-579-5210
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-18
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19189183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist