Provider Demographics
NPI:1942537972
Name:MORAN, KELLY
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:
Last Name:MORAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6205 WESTCREEK DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133-4319
Mailing Address - Country:US
Mailing Address - Phone:817-263-0962
Mailing Address - Fax:817-263-0697
Practice Address - Street 1:6205 WESTCREEK DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76133-4319
Practice Address - Country:US
Practice Address - Phone:817-263-0962
Practice Address - Fax:817-263-0697
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-12
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX46780183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist