Provider Demographics
NPI:1508373549
Name:KATELY, KODI
Entity Type:Individual
Prefix:
First Name:KODI
Middle Name:
Last Name:KATELY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9600 N METRO PKWY W
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85051-1402
Mailing Address - Country:US
Mailing Address - Phone:480-337-0256
Mailing Address - Fax:
Practice Address - Street 1:9600 N METRO PKWY W
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85051-1402
Practice Address - Country:US
Practice Address - Phone:480-337-0256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-29
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS022669183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist