Provider Demographics
NPI:1851937767
Name:RACEK, KELLY GAIL (PHARMD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:GAIL
Last Name:RACEK
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 1:1217 E IRELAND RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-3448
Mailing Address - Country:US
Mailing Address - Phone:574-291-0740
Mailing Address - Fax:
Practice Address - Street 1:1217 E IRELAND RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-3448
Practice Address - Country:US
Practice Address - Phone:574-291-0740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-26
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26024736A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist