Provider Demographics
NPI:1245237502
Name:KELSON DRUG, INC.
Entity Type:Organization
Organization Name:KELSON DRUG, INC.
Other - Org Name:KELSON DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER/CERT.PHARMACY TECHNICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:TEW
Authorized Official - Suffix:
Authorized Official - Credentials:CPHT
Authorized Official - Phone:850-526-2839
Mailing Address - Street 1:3008 JEFFERSON ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32446-2318
Mailing Address - Country:US
Mailing Address - Phone:850-526-2839
Mailing Address - Fax:850-526-5259
Practice Address - Street 1:3008 JEFFERSON ST
Practice Address - Street 2:SUITE B
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-2318
Practice Address - Country:US
Practice Address - Phone:850-526-2839
Practice Address - Fax:850-526-5259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-01
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH7691333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1041754OtherNABP
FL104673000Medicaid