Provider Demographics
NPI:1225632664
Name:SMITH, BRIAN KELLY (RPH)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:KELLY
Last Name:SMITH
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 N WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD CITY
Mailing Address - State:IN
Mailing Address - Zip Code:47348-1358
Mailing Address - Country:US
Mailing Address - Phone:765-348-4134
Mailing Address - Fax:765-348-1067
Practice Address - Street 1:1700 N WALNU ST
Practice Address - Street 2:
Practice Address - City:HARTFORD CITY
Practice Address - State:IN
Practice Address - Zip Code:47348
Practice Address - Country:US
Practice Address - Phone:765-348-4134
Practice Address - Fax:765-348-1067
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-25
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26015406A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN26015406AOtherPHARMACIST LICENSE