Provider Demographics
NPI:1629791884
Name:KELLY, ANDREW PERRY (PHARMD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:PERRY
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 1:1930 E MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71220-4034
Mailing Address - Country:US
Mailing Address - Phone:318-281-7410
Mailing Address - Fax:318-281-7890
Practice Address - Street 1:1930 E MADISON AVE
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-4034
Practice Address - Country:US
Practice Address - Phone:318-281-7410
Practice Address - Fax:318-281-7890
Is Sole Proprietor?:No
Enumeration Date:2022-09-22
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA024547183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist