Provider Demographics
NPI:1336142942
Name:KELLY, MICHAEL PAUL (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:PAUL
Last Name:KELLY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1830 24TH ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-8148
Mailing Address - Country:US
Mailing Address - Phone:206-200-7079
Mailing Address - Fax:
Practice Address - Street 1:3750 CHEMAWA RD NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1119
Practice Address - Country:US
Practice Address - Phone:503-304-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH000521981835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy