Provider Demographics
NPI:1942899067
Name:ENGLE, KELLEY (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:ENGLE
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:
Other - Last Name:KERSCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMACIST
Mailing Address - Street 1:4954 BAYSIDE LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:STOW
Mailing Address - State:OH
Mailing Address - Zip Code:44224-6041
Mailing Address - Country:US
Mailing Address - Phone:330-342-0135
Mailing Address - Fax:
Practice Address - Street 1:4954 BAYSIDE LAKE BLVD
Practice Address - Street 2:
Practice Address - City:STOW
Practice Address - State:OH
Practice Address - Zip Code:44224-6041
Practice Address - Country:US
Practice Address - Phone:330-342-0135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-3-22134183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist