Provider Demographics
NPI:1659656155
Name:BALYEAT, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BALYEAT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2012 NORTH WAYNE STREET
Mailing Address - Street 2:WALGREENS PHARMACY
Mailing Address - City:ANGOLA
Mailing Address - State:IN
Mailing Address - Zip Code:46703
Mailing Address - Country:US
Mailing Address - Phone:260-665-5560
Mailing Address - Fax:260-665-5569
Practice Address - Street 1:2012 NORTH WAYNE STREET
Practice Address - Street 2:
Practice Address - City:ANGOLA
Practice Address - State:IN
Practice Address - Zip Code:46703
Practice Address - Country:US
Practice Address - Phone:260-665-5560
Practice Address - Fax:260-665-5569
Is Sole Proprietor?:No
Enumeration Date:2011-10-15
Last Update Date:2011-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26023420A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist