Provider Demographics
NPI:1578560892
Name:KELLY, MICHAEL PATRICK (RPH MBA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:PATRICK
Last Name:KELLY
Suffix:
Gender:M
Credentials:RPH MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 S 500 E
Mailing Address - Street 2:SUITE 160
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1959
Mailing Address - Country:US
Mailing Address - Phone:801-587-6325
Mailing Address - Fax:801-236-8043
Practice Address - Street 1:127 S 500 E
Practice Address - Street 2:SUITE 160
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1959
Practice Address - Country:US
Practice Address - Phone:801-587-6325
Practice Address - Fax:801-236-8043
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT142148183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist