Provider Demographics
NPI:1164708608
Name:SNYDER, KELLY EUGENE (PHARMD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:EUGENE
Last Name:SNYDER
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 1:405 COLONIAL ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37760-3857
Mailing Address - Country:US
Mailing Address - Phone:865-414-0512
Mailing Address - Fax:
Practice Address - Street 1:1224 GAY ST
Practice Address - Street 2:
Practice Address - City:DANDRIDGE
Practice Address - State:TN
Practice Address - Zip Code:37725-4720
Practice Address - Country:US
Practice Address - Phone:865-397-3444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-28
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36030183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist