Provider Demographics
NPI:1760552012
Name:ZACOT, KELLY JO (RPH)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JO
Last Name:ZACOT
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 1:84 MARY LEE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLES TOWN
Mailing Address - State:WV
Mailing Address - Zip Code:25414-4223
Mailing Address - Country:US
Mailing Address - Phone:304-725-8747
Mailing Address - Fax:
Practice Address - Street 1:510 BUTLER AVE
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-9990
Practice Address - Country:US
Practice Address - Phone:304-263-0811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0004946183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist