Provider Demographics
NPI:1508532524
Name:MALONE, KELLY MARIE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:MALONE
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 1:14529 FOX KNOLL DR
Mailing Address - Street 2:
Mailing Address - City:S CHESTERFLD
Mailing Address - State:VA
Mailing Address - Zip Code:23834-5856
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11895 W BROAD ST
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23233-1065
Practice Address - Country:US
Practice Address - Phone:804-337-5390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202219835183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist