Provider Demographics
NPI:1629324462
Name:SHAW, KELLI KRISTINE (PHARMD)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:KRISTINE
Last Name:SHAW
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 1:7461 BLACKMON RD
Mailing Address - Street 2:APT. #5108
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-8400
Mailing Address - Country:US
Mailing Address - Phone:785-826-7851
Mailing Address - Fax:
Practice Address - Street 1:710 CENTER ST
Practice Address - Street 2:DEPARTMENT OF PHARMACY
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-1527
Practice Address - Country:US
Practice Address - Phone:706-571-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-30
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-15190183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist