Provider Demographics
NPI:1356691372
Name:DEBERRY, KELLY ALYSE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ALYSE
Last Name:DEBERRY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:ALYSE
Other - Last Name:HAYNES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:8779 MCKENZIE FARM DR
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-5990
Mailing Address - Country:US
Mailing Address - Phone:256-679-2018
Mailing Address - Fax:
Practice Address - Street 1:1155 BATTLEFIELD PKWY
Practice Address - Street 2:
Practice Address - City:FORT OGLETHORPE
Practice Address - State:GA
Practice Address - Zip Code:30742-3960
Practice Address - Country:US
Practice Address - Phone:762-887-6046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-17
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH026877183500000X
ALP17049183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist