Provider Demographics
NPI:1376120188
Name:KELLEY, SUE ELLEN (R PH)
Entity Type:Individual
Prefix:MS
First Name:SUE
Middle Name:ELLEN
Last Name:KELLEY
Suffix:
Gender:F
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 S 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:AL
Mailing Address - Zip Code:36344-1615
Mailing Address - Country:US
Mailing Address - Phone:334-588-2442
Mailing Address - Fax:334-588-2447
Practice Address - Street 1:112 S 4TH AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:AL
Practice Address - Zip Code:36344-1615
Practice Address - Country:US
Practice Address - Phone:334-588-2442
Practice Address - Fax:334-588-2447
Is Sole Proprietor?:No
Enumeration Date:2021-03-26
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL11237183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist