Provider Demographics
NPI:1750926705
Name:BOLEY, KELLI SUE (PHARMD)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:SUE
Last Name:BOLEY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19100 MURDOCK CIRCLE
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33948
Mailing Address - Country:US
Mailing Address - Phone:941-625-8825
Mailing Address - Fax:941-625-4685
Practice Address - Street 1:19100 MURDOCK CIRCLE
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948
Practice Address - Country:US
Practice Address - Phone:941-625-8825
Practice Address - Fax:941-625-4685
Is Sole Proprietor?:No
Enumeration Date:2019-11-14
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS44708183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist