Provider Demographics
NPI:1942653522
Name:HANNON, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HANNON
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 1:28 SHORELINE DR
Mailing Address - Street 2:
Mailing Address - City:FOXBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02035-1115
Mailing Address - Country:US
Mailing Address - Phone:508-965-0518
Mailing Address - Fax:
Practice Address - Street 1:221 UNIVERSITY AVE
Practice Address - Street 2:CVS PHARMACY
Practice Address - City:WESTWOOD
Practice Address - State:MA
Practice Address - Zip Code:02090-2333
Practice Address - Country:US
Practice Address - Phone:781-410-6946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-19
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH236693183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist