Provider Demographics
NPI:1790119857
Name:KELLY, KIM MARIE (RPH)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:MARIE
Last Name:KELLY
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 1:1401 BOMBING RANGE RD
Mailing Address - Street 2:
Mailing Address - City:WEST RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99353-8001
Mailing Address - Country:US
Mailing Address - Phone:509-967-8008
Mailing Address - Fax:509-967-8096
Practice Address - Street 1:1401 BOMBING RANGE RD
Practice Address - Street 2:
Practice Address - City:WEST RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99353-8001
Practice Address - Country:US
Practice Address - Phone:509-967-8008
Practice Address - Fax:509-967-8096
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-26
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00015160183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6029136Medicaid