MEDICARE: MRS. KELLEY MARIE MESSMER RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	051038751	IL
2	183500000X	Pharmacist	043139	MO

General Provider Information

NPI Number	:	1023392628
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLEY MARIE MESSMER RPH

Provider Business Mailing Address
First Line	:	5425 N PROSPECT RD
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61614-5274
Country	:	US
Telephone Number	:	309-688-9081
Fax Number	:

Provider Business Practice Location Address
First Line	:	2106 W TOWNLINE RD
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61615-1547
Country	:	US
Telephone Number	:	309-692-2826
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/01/2011
Last Update Date	:	10/01/2011

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