Provider Demographics
NPI:1679296446
Name:COOK, KELLEY
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:COOK
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 1:2009 COUNTRY VIEW LN
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-1527
Mailing Address - Country:US
Mailing Address - Phone:302-216-1878
Mailing Address - Fax:
Practice Address - Street 1:3157 NATIONAL PIKE
Practice Address - Street 2:
Practice Address - City:RICHEYVILLE
Practice Address - State:PA
Practice Address - Zip Code:15358-1004
Practice Address - Country:US
Practice Address - Phone:724-632-6555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP448546183500000X
FL58443183500000X
WVRP5121183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist