Provider Demographics
NPI:1265851802
Name:KELLY, JEREMY
Entity type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:
Last Name:KELLY
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 1:2751 BEAVER RUN BLVD
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29575-5381
Mailing Address - Country:US
Mailing Address - Phone:843-215-3856
Mailing Address - Fax:843-215-3859
Practice Address - Street 1:2751 BEAVER RUN BLVD
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29575-5381
Practice Address - Country:US
Practice Address - Phone:843-215-3856
Practice Address - Fax:843-215-3859
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-10
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9604183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist