Provider Demographics
NPI:1942492053
Name:BENNETT, KELLIE L (PHARMD)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:L
Last Name:BENNETT
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 1:7233 WOODWARD AVE
Mailing Address - Street 2:APT 211
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-2441
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:555 31ST ST
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1235
Practice Address - Country:US
Practice Address - Phone:630-515-6272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL51291881183500000X
IN26022036A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist