Provider Demographics
NPI:1417380015
Name:GROSSMAN, KELLY MARIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:GROSSMAN
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 1:44011 E CAMELLIA CT
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93535
Mailing Address - Country:US
Mailing Address - Phone:661-992-1726
Mailing Address - Fax:
Practice Address - Street 1:44011 E CAMELLIA CT
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93535
Practice Address - Country:US
Practice Address - Phone:661-992-1726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-19
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR12958183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist