Provider Demographics
NPI:1619562519
Name:KELLEY, SHANNON (PHARMD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:KELLEY
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 1:26 COWLES RD
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06798-1706
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:365 MONTAUK AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4700
Practice Address - Country:US
Practice Address - Phone:860-442-0711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-03
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0014556183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist