Provider Demographics
NPI:1528412749
Name:NULL, KELLY (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:NULL
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 S TYLER ST
Mailing Address - Street 2:ATTN: EMPLOYEE PHARMACY
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-2330
Mailing Address - Country:US
Mailing Address - Phone:985-898-4432
Mailing Address - Fax:985-898-4363
Practice Address - Street 1:1202 S TYLER ST
Practice Address - Street 2:ATTN: EMPLOYEE PHARMACY
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-2330
Practice Address - Country:US
Practice Address - Phone:985-898-4432
Practice Address - Fax:985-898-4363
Is Sole Proprietor?:No
Enumeration Date:2016-04-14
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA18196183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist