Provider Demographics
NPI:1962002337
Name:KELLEY, MALYNDA
Entity Type:Individual
Prefix:
First Name:MALYNDA
Middle Name:
Last Name:KELLEY
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 1:24 ADAMS CIR
Mailing Address - Street 2:
Mailing Address - City:REHOBOTH
Mailing Address - State:MA
Mailing Address - Zip Code:02769-1431
Mailing Address - Country:US
Mailing Address - Phone:508-208-8332
Mailing Address - Fax:
Practice Address - Street 1:1180 FALL RIVER AVE
Practice Address - Street 2:
Practice Address - City:SEEKONK
Practice Address - State:MA
Practice Address - Zip Code:02771-5936
Practice Address - Country:US
Practice Address - Phone:508-336-5308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH23330183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist