Provider Demographics
NPI:1598175481
Name:KELLEY, DAVID SR
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:KELLEY
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2949 SHOREWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-3126
Mailing Address - Country:US
Mailing Address - Phone:810-434-9802
Mailing Address - Fax:
Practice Address - Street 1:4475 24TH AVE.
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059
Practice Address - Country:US
Practice Address - Phone:810-385-2164
Practice Address - Fax:810-385-2165
Is Sole Proprietor?:No
Enumeration Date:2014-05-01
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020242061835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy