Provider Demographics
NPI:1245393206
Name:GROTH, KELLY L (PHARMD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:GROTH
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 1:2105 RUBY WAY
Mailing Address - Street 2:
Mailing Address - City:UNION GAP
Mailing Address - State:WA
Mailing Address - Zip Code:98903-4023
Mailing Address - Country:US
Mailing Address - Phone:509-945-4128
Mailing Address - Fax:
Practice Address - Street 1:2811 TIETON DR
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902
Practice Address - Country:US
Practice Address - Phone:509-249-5171
Practice Address - Fax:509-249-5239
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00021591183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist