Provider Demographics
NPI:1104045707
Name:KELLY, MICHAEL WALTER (PHARMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WALTER
Last Name:KELLY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 PHARMACY BUILDING
Mailing Address - Street 2:COLLEGE OF PHARMACY
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1112
Mailing Address - Country:US
Mailing Address - Phone:319-335-7644
Mailing Address - Fax:
Practice Address - Street 1:COLLEGE OF PHARMACY
Practice Address - Street 2:110 PHARMACY BUILDING
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1112
Practice Address - Country:US
Practice Address - Phone:319-335-7644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA16674183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist