Provider Demographics
NPI:1942814033
Name:EARHART, KELLY RAY (PHARM D)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RAY
Last Name:EARHART
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4529 S COVERED WAGON TRL
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-8546
Mailing Address - Country:US
Mailing Address - Phone:580-977-7153
Mailing Address - Fax:
Practice Address - Street 1:305 S 5TH ST
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-5832
Practice Address - Country:US
Practice Address - Phone:580-249-3062
Practice Address - Fax:580-249-3736
Is Sole Proprietor?:No
Enumeration Date:2020-09-04
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13003183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK13003OtherPHARMACIST