Provider Demographics
NPI:1780908582
Name:KISTLER, KELLY (PHARMD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:KISTLER
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 1:20710 N 51ST DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-9369
Mailing Address - Country:US
Mailing Address - Phone:602-790-1802
Mailing Address - Fax:
Practice Address - Street 1:23620 N 20TH DR
Practice Address - Street 2:SUITE 12
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85085-0621
Practice Address - Country:US
Practice Address - Phone:602-790-1802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-23
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS017269183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist