Provider Demographics
NPI:1255990339
Name:KEHOE, MARLENE ELISE
Entity type:Individual
Prefix:
First Name:MARLENE
Middle Name:ELISE
Last Name:KEHOE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44405 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-5023
Mailing Address - Country:US
Mailing Address - Phone:248-858-3064
Mailing Address - Fax:248-858-6031
Practice Address - Street 1:44405 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-5023
Practice Address - Country:US
Practice Address - Phone:248-858-3064
Practice Address - Fax:248-858-6031
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302023210183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist