Provider Demographics
NPI:1992831507
Name:FORTIER, KELLIE LEIGH (PHARMD)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:LEIGH
Last Name:FORTIER
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 1:4098 E MORRISON RANCH PKWY
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-3091
Mailing Address - Country:US
Mailing Address - Phone:480-412-5616
Mailing Address - Fax:480-412-8763
Practice Address - Street 1:1400 S DOBSON RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-4707
Practice Address - Country:US
Practice Address - Phone:480-412-5616
Practice Address - Fax:480-412-8763
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13815183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist