Provider Demographics
NPI:1912499583
Name:HARRELL, KELLY JEANINE (PD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JEANINE
Last Name:HARRELL
Suffix:
Gender:F
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 BULL RUN LOOP
Mailing Address - Street 2:
Mailing Address - City:CABOT
Mailing Address - State:AR
Mailing Address - Zip Code:72023-9401
Mailing Address - Country:US
Mailing Address - Phone:501-259-0564
Mailing Address - Fax:
Practice Address - Street 1:25 BULL RUN LOOP
Practice Address - Street 2:
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023-9401
Practice Address - Country:US
Practice Address - Phone:501-259-0564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-30
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD07555183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist