Provider Demographics
NPI:1376143818
Name:TATE, KELLI KATHLEEN (PHARMD)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:KATHLEEN
Last Name:TATE
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 1:2980 DEERRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-4058
Mailing Address - Country:US
Mailing Address - Phone:618-550-5929
Mailing Address - Fax:
Practice Address - Street 1:103 W POLK ST
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:MO
Practice Address - Zip Code:65355-3297
Practice Address - Country:US
Practice Address - Phone:660-438-2207
Practice Address - Fax:660-438-4304
Is Sole Proprietor?:No
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.300969183500000X
MO2017008178183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist