Provider Demographics
NPI:1922336494
Name:KELLEY, BIRDIE MAE (RPH)
Entity Type:Individual
Prefix:
First Name:BIRDIE
Middle Name:MAE
Last Name:KELLEY
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 1:3403 TEXAS PKWY
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77489-5202
Mailing Address - Country:US
Mailing Address - Phone:281-438-3557
Mailing Address - Fax:281-438-7820
Practice Address - Street 1:3403 TEXAS PKWY
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77489-5202
Practice Address - Country:US
Practice Address - Phone:281-438-3557
Practice Address - Fax:281-438-7820
Is Sole Proprietor?:No
Enumeration Date:2009-11-22
Last Update Date:2009-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28366183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX28366OtherTEXAS STATE BOARD OF PHARMACY