Provider Demographics
NPI:1780865501
Name:MILICH, KELLIE JO (PHARM D)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:JO
Last Name:MILICH
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:JO
Other - Last Name:VARICHAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:FOND DU LAC HUMAN SERVICES DIVISION
Mailing Address - Street 2:927 TRETTEL LANE
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720
Mailing Address - Country:US
Mailing Address - Phone:218-879-1227
Mailing Address - Fax:218-878-2188
Practice Address - Street 1:MASKIKI WAAKAAIGAN
Practice Address - Street 2:1433 E. FRANKLIN AVENUE SUITE 11 & 13B
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404
Practice Address - Country:US
Practice Address - Phone:612-874-9128
Practice Address - Fax:612-874-9128
Is Sole Proprietor?:No
Enumeration Date:2007-11-20
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN118954183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist