Provider Demographics
NPI:1992023899
Name:SHIELDS, KELLY (PHARMD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 S MAIN ST
Mailing Address - Street 2:COLLEGE OF PHARMACY
Mailing Address - City:ADA
Mailing Address - State:OH
Mailing Address - Zip Code:45810-6000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:525 S MAIN ST
Practice Address - Street 2:COLLEGE OF PHARMACY
Practice Address - City:ADA
Practice Address - State:OH
Practice Address - Zip Code:45810-6000
Practice Address - Country:US
Practice Address - Phone:419-772-2307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-17
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-2-28340183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist