Provider Demographics
NPI:1679105670
Name:KELLY, KRISTINE MARIE (RPH)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 S WAYNE RD
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48186-5430
Mailing Address - Country:US
Mailing Address - Phone:734-721-3444
Mailing Address - Fax:734-728-4197
Practice Address - Street 1:1750 S WAYNE RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48186-5430
Practice Address - Country:US
Practice Address - Phone:734-721-3444
Practice Address - Fax:734-728-4197
Is Sole Proprietor?:No
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020294201835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist