Provider Demographics
NPI:1922307024
Name:BUCHANAN, KELLY RENEA
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:RENEA
Last Name:BUCHANAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1343 MIDDLE SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:KINGSLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31548-6227
Mailing Address - Country:US
Mailing Address - Phone:601-323-7973
Mailing Address - Fax:
Practice Address - Street 1:881 USS JAMES MADISON RD
Practice Address - Street 2:NAVAL SUBMARINE BASE
Practice Address - City:KINGS BAY
Practice Address - State:GA
Practice Address - Zip Code:31547-2531
Practice Address - Country:US
Practice Address - Phone:912-573-4264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-15
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician