Provider Demographics
NPI:1881977585
Name:SHIRLEY, KELLY (RPH)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SHIRLEY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1666 CHESTNUT AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-1608
Mailing Address - Country:US
Mailing Address - Phone:321-441-5310
Mailing Address - Fax:
Practice Address - Street 1:330 S ORLANDO AVE
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-5606
Practice Address - Country:US
Practice Address - Phone:407-629-4669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS020730183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist