Provider Demographics
NPI:1477839322
Name:BREEMEERSCH, KELLY LYNN (RPH)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:BREEMEERSCH
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 1:5598 BRICKSTONE CT
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-4822
Mailing Address - Country:US
Mailing Address - Phone:651-415-1134
Mailing Address - Fax:
Practice Address - Street 1:10686 UNIVERSITY AVE NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55448-6141
Practice Address - Country:US
Practice Address - Phone:763-755-1259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN115829183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist