Provider Demographics
NPI:1609465376
Name:KELLY, PAYTON THOMAS (PHARMD)
Entity Type:Individual
Prefix:
First Name:PAYTON
Middle Name:THOMAS
Last Name:KELLY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8302 SPOTTER DR
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-7290
Mailing Address - Country:US
Mailing Address - Phone:336-940-7455
Mailing Address - Fax:
Practice Address - Street 1:1401 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-9024
Practice Address - Country:US
Practice Address - Phone:919-567-2846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-15
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC30194183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist