Provider Demographics
NPI:1952742322
Name:KELLETT, JUSTIN M (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:M
Last Name:KELLETT
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 BEAUCLAIR DRIVE
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29680
Mailing Address - Country:US
Mailing Address - Phone:864-962-8991
Mailing Address - Fax:
Practice Address - Street 1:698 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29680-6708
Practice Address - Country:US
Practice Address - Phone:864-962-8994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-12
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12570183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist