Provider Demographics
NPI:1639230881
Name:VANKIRK, KELLY JOE (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:JOE
Last Name:VANKIRK
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5776 KAY DR
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37860-8903
Mailing Address - Country:US
Mailing Address - Phone:205-821-3000
Mailing Address - Fax:423-733-2322
Practice Address - Street 1:140 CHURCH ST
Practice Address - Street 2:
Practice Address - City:SNEEDVILLE
Practice Address - State:TN
Practice Address - Zip Code:37869
Practice Address - Country:US
Practice Address - Phone:423-733-2322
Practice Address - Fax:423-733-2140
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000022407183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1790796340OtherPHARMACY
TN9448755Medicaid