Provider Demographics
NPI:1407106784
Name:FAIRLEY, KELLI DENISE (PHARM D)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:DENISE
Last Name:FAIRLEY
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 NW 190TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33056-2733
Mailing Address - Country:US
Mailing Address - Phone:850-712-7223
Mailing Address - Fax:866-788-9477
Practice Address - Street 1:2401 W ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33069-2634
Practice Address - Country:US
Practice Address - Phone:954-861-5672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-14
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL49753183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist