Provider Demographics
NPI:1609148741
Name:ALSUP, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:ALSUP
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 1:817 SAINT ANDREWS RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-5828
Mailing Address - Country:US
Mailing Address - Phone:803-551-1145
Mailing Address - Fax:
Practice Address - Street 1:817 SAINT ANDREWS RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-5828
Practice Address - Country:US
Practice Address - Phone:803-551-1145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-06
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12357183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist