Provider Demographics
NPI:1194359869
Name:KING, KELSEY
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:KING
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 1:1720 WATERFRONT DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52240-4458
Mailing Address - Country:US
Mailing Address - Phone:319-354-7121
Mailing Address - Fax:319-354-7025
Practice Address - Street 1:1720 WATERFRONT DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52240-4458
Practice Address - Country:US
Practice Address - Phone:319-354-7121
Practice Address - Fax:319-354-7025
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-02
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA22742183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist