Provider Demographics
NPI:1316229859
Name:KELLUM, KENDALL WILLIS (RPH)
Entity Type:Individual
Prefix:MRS
First Name:KENDALL
Middle Name:WILLIS
Last Name:KELLUM
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4768 SHORE DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-2713
Mailing Address - Country:US
Mailing Address - Phone:757-460-1290
Mailing Address - Fax:757-460-1547
Practice Address - Street 1:4768 SHORE DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-2713
Practice Address - Country:US
Practice Address - Phone:757-460-1290
Practice Address - Fax:757-460-1547
Is Sole Proprietor?:No
Enumeration Date:2011-09-11
Last Update Date:2011-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202005020183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist