Provider Demographics
NPI:1134422413
Name:ANDERSON, KELLY (PHARMD,CCP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PHARMD,CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5525 S PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-4400
Mailing Address - Country:US
Mailing Address - Phone:773-432-0100
Mailing Address - Fax:773-432-0101
Practice Address - Street 1:5525 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-4400
Practice Address - Country:US
Practice Address - Phone:773-432-0100
Practice Address - Fax:773-432-0101
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-08
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03147600183500000X
NY054233183500000X
IL051295532183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist