Provider Demographics
NPI:1164822631
Name:LAUGHLIN, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:LAUGHLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 E PALM CANYON DR APT 24
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92264-4840
Mailing Address - Country:US
Mailing Address - Phone:714-615-2651
Mailing Address - Fax:
Practice Address - Street 1:33975 DATE PALM DR
Practice Address - Street 2:
Practice Address - City:CATHEDRAL CITY
Practice Address - State:CA
Practice Address - Zip Code:92234-4736
Practice Address - Country:US
Practice Address - Phone:760-202-3533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-03
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA71080183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist