Provider Demographics
NPI:1942756028
Name:SMITH, KELLY (PHARMD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 N IRON BRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-4932
Mailing Address - Country:US
Mailing Address - Phone:509-444-8888
Mailing Address - Fax:509-444-7806
Practice Address - Street 1:401 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:WA
Practice Address - Zip Code:99006-8238
Practice Address - Country:US
Practice Address - Phone:509-444-8200
Practice Address - Fax:509-434-0392
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-29
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60565725183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPH60565725OtherPHARMACIST
WAPH60565725Medicaid