Provider Demographics
NPI:1417513003
Name:KELLY, WILLIAM MICHAEL (RPH)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:MICHAEL
Last Name:KELLY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 LAURELWOOD DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97530-9424
Mailing Address - Country:US
Mailing Address - Phone:541-821-1890
Mailing Address - Fax:
Practice Address - Street 1:3528 LONE PINE RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-5668
Practice Address - Country:US
Practice Address - Phone:541-973-2367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-19
Last Update Date:2019-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH0014997183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist