Provider Demographics
NPI:1205178233
Name:MICHALK, KEELY NICOLE (PHARM D, RPH)
Entity Type:Individual
Prefix:
First Name:KEELY
Middle Name:NICOLE
Last Name:MICHALK
Suffix:
Gender:F
Credentials:PHARM D, RPH
Other - Prefix:
Other - First Name:KEELY
Other - Middle Name:NICOLE
Other - Last Name:BOUDREAUX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARM D, RPH
Mailing Address - Street 1:4800B HIGHWAY 365
Mailing Address - Street 2:
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77642-7403
Mailing Address - Country:US
Mailing Address - Phone:409-722-4066
Mailing Address - Fax:409-722-4588
Practice Address - Street 1:4800B HIGHWAY 365
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77642-7403
Practice Address - Country:US
Practice Address - Phone:409-722-4066
Practice Address - Fax:409-722-4588
Is Sole Proprietor?:No
Enumeration Date:2013-03-15
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX44108183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist