Provider Demographics
NPI:1649565912
Name:MARINI, KELLY ANNE (PHARM D)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANNE
Last Name:MARINI
Suffix:
Gender:F
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 1:555 S RAND RD
Mailing Address - Street 2:T-1036
Mailing Address - City:LAKE ZURICH
Mailing Address - State:IL
Mailing Address - Zip Code:60047-2356
Mailing Address - Country:US
Mailing Address - Phone:847-726-2584
Mailing Address - Fax:847-726-2584
Practice Address - Street 1:555 S RAND RD
Practice Address - Street 2:T-1036
Practice Address - City:LAKE ZURICH
Practice Address - State:IL
Practice Address - Zip Code:60047-2356
Practice Address - Country:US
Practice Address - Phone:847-726-2584
Practice Address - Fax:847-726-2584
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051289620183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL410215170036Medicaid