Provider Demographics
NPI:1205260650
Name:KELLY, MICHAEL PATRICK JR (RPH)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:PATRICK
Last Name:KELLY
Suffix:JR
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5711 MESA MOUNTAIN WAY
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80923-3450
Mailing Address - Country:US
Mailing Address - Phone:303-915-3655
Mailing Address - Fax:
Practice Address - Street 1:425 S CHERRY ST STE 200
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80246-1229
Practice Address - Country:US
Practice Address - Phone:303-524-6126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-21
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO16256183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO16356Medicaid