Provider Demographics
NPI:1750798179
Name:SHELLEY, KYLE (PHARMD, RPH)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:
Last Name:SHELLEY
Suffix:
Gender:M
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11901 FULTON ST E
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:49331-8613
Mailing Address - Country:US
Mailing Address - Phone:616-897-4710
Mailing Address - Fax:
Practice Address - Street 1:11 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:MI
Practice Address - Zip Code:49345-1325
Practice Address - Country:US
Practice Address - Phone:616-887-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-17
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302039914183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist