Provider Demographics
NPI:1760881809
Name:SMITH, KELLI ANN (PHARMD)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4122 AUTUMN CREST DR
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MI
Mailing Address - Zip Code:49419-9119
Mailing Address - Country:US
Mailing Address - Phone:616-218-5838
Mailing Address - Fax:
Practice Address - Street 1:4122 AUTUMN CREST DR
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MI
Practice Address - Zip Code:49419-9119
Practice Address - Country:US
Practice Address - Phone:616-218-5838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302039876183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302039876OtherPHARMACISTS LICENSE