Provider Demographics
NPI:1952706533
Name:O'DANIEL, KELVIN
Entity Type:Individual
Prefix:MR
First Name:KELVIN
Middle Name:
Last Name:O'DANIEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 N SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:ARKANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67005-8813
Mailing Address - Country:US
Mailing Address - Phone:620-442-2051
Mailing Address - Fax:620-442-6622
Practice Address - Street 1:2701 N SUMMIT ST
Practice Address - Street 2:
Practice Address - City:ARKANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:67005-8813
Practice Address - Country:US
Practice Address - Phone:620-442-2051
Practice Address - Fax:620-442-6622
Is Sole Proprietor?:No
Enumeration Date:2014-10-25
Last Update Date:2014-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-10411183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist