Provider Demographics
NPI:1831227164
Name:STOVALL, KELLY ELISE (RPH)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ELISE
Last Name:STOVALL
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 1:1630 COUNTY ROAD 460
Mailing Address - Street 2:
Mailing Address - City:HAWLEY
Mailing Address - State:TX
Mailing Address - Zip Code:79525-2532
Mailing Address - Country:US
Mailing Address - Phone:325-537-9377
Mailing Address - Fax:325-823-3038
Practice Address - Street 1:1150 W COURT PLZ
Practice Address - Street 2:
Practice Address - City:ANSON
Practice Address - State:TX
Practice Address - Zip Code:79501-4315
Practice Address - Country:US
Practice Address - Phone:325-823-3203
Practice Address - Fax:325-823-3038
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35611183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist