Provider Demographics
NPI:1255618559
Name:KELLY, MATTHEW K (PHARM D,)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:K
Last Name:KELLY
Suffix:
Gender:M
Credentials:PHARM D,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 LEXINGTON AVE N
Mailing Address - Street 2:T0619
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-2916
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3800 LEXINGTON AVE N
Practice Address - Street 2:T0619
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-2916
Practice Address - Country:US
Practice Address - Phone:651-486-0649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-15
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN119746183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist