Provider Demographics
NPI:1225326325
Name:HANCOCK, KELLY LYNN (PHARMD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:HANCOCK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12376 W TEVOIT ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-5372
Mailing Address - Country:US
Mailing Address - Phone:208-308-5412
Mailing Address - Fax:
Practice Address - Street 1:3499 E FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5848
Practice Address - Country:US
Practice Address - Phone:208-884-1286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6430183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist