Provider Demographics
NPI:1356627004
Name:COMBRINK, KELLY (DPH)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:COMBRINK
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:627 LAKES DR
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-5061
Mailing Address - Country:US
Mailing Address - Phone:918-671-1190
Mailing Address - Fax:
Practice Address - Street 1:2330 CHANDLER RD
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74403-4627
Practice Address - Country:US
Practice Address - Phone:918-681-4910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14474183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist