Provider Demographics
NPI:1639770795
Name:KELLEY, THOMAS DAVID (RPH)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:DAVID
Last Name:KELLEY
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 1:1548 JASPER RD
Mailing Address - Street 2:
Mailing Address - City:PIKETON
Mailing Address - State:OH
Mailing Address - Zip Code:45661-9054
Mailing Address - Country:US
Mailing Address - Phone:740-357-6378
Mailing Address - Fax:
Practice Address - Street 1:990 W EMMITT AVE
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690-1095
Practice Address - Country:US
Practice Address - Phone:740-947-0300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03225161183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist