Provider Demographics
NPI:1396357984
Name:SMITH, KELLY LYNN (PHARMD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:SMITH
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 1:108 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IL
Mailing Address - Zip Code:61856-1636
Mailing Address - Country:US
Mailing Address - Phone:217-762-2056
Mailing Address - Fax:
Practice Address - Street 1:108 N MARKET ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IL
Practice Address - Zip Code:61856-1636
Practice Address - Country:US
Practice Address - Phone:217-762-2056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.293555183500000X
IL293555183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist