Provider Demographics
NPI:1821070913
Name:DURHAM, KELLI STEPHANIE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:STEPHANIE
Last Name:DURHAM
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 1:951 FOX HAVEN CT
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-4950
Mailing Address - Country:US
Mailing Address - Phone:912-368-6658
Mailing Address - Fax:
Practice Address - Street 1:230 DUNCAN DR
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31409-5102
Practice Address - Country:US
Practice Address - Phone:912-315-4540
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO042247183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist