Provider Demographics
NPI:1164028320
Name:MCNINCH, KELLY ELIZABETH (RPH)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ELIZABETH
Last Name:MCNINCH
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:256 CARDIN CIR
Mailing Address - Street 2:
Mailing Address - City:ENOLA
Mailing Address - State:AR
Mailing Address - Zip Code:72047-8223
Mailing Address - Country:US
Mailing Address - Phone:501-454-3020
Mailing Address - Fax:501-796-0134
Practice Address - Street 1:1086 MAIN ST
Practice Address - Street 2:
Practice Address - City:VILONIA
Practice Address - State:AR
Practice Address - Zip Code:72173-8003
Practice Address - Country:US
Practice Address - Phone:501-796-0150
Practice Address - Fax:501-796-0134
Is Sole Proprietor?:No
Enumeration Date:2020-12-11
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD07721183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist