Provider Demographics
NPI:1235504358
Name:WARREN, KELLY MARIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:WARREN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:1308 HWY 33 SOUTH
Mailing Address - Street 2:
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720
Mailing Address - Country:US
Mailing Address - Phone:218-310-0524
Mailing Address - Fax:
Practice Address - Street 1:1308 HIGHWAY 33 S
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-2653
Practice Address - Country:US
Practice Address - Phone:218-878-0676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-01
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18193-40183500000X
MN122428183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist