Provider Demographics
NPI:1629081278
Name:MINK, KELLY (RPH)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MINK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 W MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:KY
Mailing Address - Zip Code:40444-1041
Mailing Address - Country:US
Mailing Address - Phone:859-792-4983
Mailing Address - Fax:859-792-3511
Practice Address - Street 1:330 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:KY
Practice Address - Zip Code:40444-1058
Practice Address - Country:US
Practice Address - Phone:859-792-4611
Practice Address - Fax:859-792-3511
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY007677183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54013875Medicaid
KY54013875Medicaid