Provider Demographics
NPI:1093578080
Name:HARVILL, KELLY (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HARVILL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 W SOUTH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-4074
Mailing Address - Country:US
Mailing Address - Phone:501-315-5100
Mailing Address - Fax:
Practice Address - Street 1:1016 W SOUTH ST STE 1
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-4074
Practice Address - Country:US
Practice Address - Phone:501-315-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-01
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT11174183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician