Provider Demographics
NPI:1477808129
Name:OLIVER, KELLY (RPH)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:OLIVER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13387 JONES ST
Mailing Address - Street 2:
Mailing Address - City:LAVONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30553-1164
Mailing Address - Country:US
Mailing Address - Phone:706-356-4153
Mailing Address - Fax:706-356-2849
Practice Address - Street 1:13387 JONES ST
Practice Address - Street 2:
Practice Address - City:LAVONIA
Practice Address - State:GA
Practice Address - Zip Code:30553-1164
Practice Address - Country:US
Practice Address - Phone:706-356-4153
Practice Address - Fax:706-356-2849
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH026597183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist