Provider Demographics
NPI:1649556556
Name:KELLY, JAMES HOWARD (RPH)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:HOWARD
Last Name:KELLY
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 1:1420 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48838-2621
Mailing Address - Country:US
Mailing Address - Phone:616-754-3255
Mailing Address - Fax:616-754-3291
Practice Address - Street 1:1420 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-2621
Practice Address - Country:US
Practice Address - Phone:616-754-3255
Practice Address - Fax:616-754-3291
Is Sole Proprietor?:No
Enumeration Date:2011-10-25
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302023705183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302023705OtherLICENSE NUMBER