Provider Demographics
NPI:1932702875
Name:BOLLENBACHER, KELLY
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:BOLLENBACHER
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 1:273 BUCKINGHAM PL
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684-3302
Mailing Address - Country:US
Mailing Address - Phone:727-254-1935
Mailing Address - Fax:
Practice Address - Street 1:902 CURLEW RD
Practice Address - Street 2:
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698-1901
Practice Address - Country:US
Practice Address - Phone:727-736-9208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS61863183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist