Provider Demographics
NPI:1811271869
Name:DONNELLY, VICKI C (RPH)
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:C
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 W DIXIE AVE
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2468
Mailing Address - Country:US
Mailing Address - Phone:270-982-3088
Mailing Address - Fax:270-982-3096
Practice Address - Street 1:550 W DIXIE AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2468
Practice Address - Country:US
Practice Address - Phone:270-982-3088
Practice Address - Fax:270-982-3096
Is Sole Proprietor?:No
Enumeration Date:2011-10-07
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY012078183500000X
MO043896183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist