Provider Demographics
NPI:1720413867
Name:RICHEAL, KELLY B
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:B
Last Name:RICHEAL
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 1:5505 KNOLLWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-4682
Mailing Address - Country:US
Mailing Address - Phone:563-357-9224
Mailing Address - Fax:
Practice Address - Street 1:1023 1ST AVE NE
Practice Address - Street 2:
Practice Address - City:LITTLE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56345-3336
Practice Address - Country:US
Practice Address - Phone:320-632-1639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-09
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN121460183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist