Provider Demographics
NPI:1255935128
Name:KELLEY, PATRICK L
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:L
Last Name:KELLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 WILLIAM HOWARD TAFT RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219-1713
Mailing Address - Country:US
Mailing Address - Phone:513-569-4106
Mailing Address - Fax:
Practice Address - Street 1:17 WILLIAM HOWARD TAFT RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-1713
Practice Address - Country:US
Practice Address - Phone:513-569-4106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03112942183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist