MEDICARE: DR. KERRI KELLEY PHARMD

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	2010030709	KS
2	183500000X	Pharmacist	2010030709	MO

General Provider Information

NPI Number	:	1356947022
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KERRI KELLEY PHARMD

Provider Business Mailing Address
First Line	:	501 S MADISON ST STE S
Second Line	:
City	:	WEBB CITY
State	:	MO
Zip	:	64870-2426
Country	:	US
Telephone Number	:	417-483-5292
Fax Number	:	417-392-6043

Provider Business Practice Location Address
First Line	:	501 S MADISON ST STE S
Second Line	:
City	:	WEBB CITY
State	:	MO
Zip	:	64870-2426
Country	:	US
Telephone Number	:	417-483-5292
Fax Number	:	417-392-6043

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

Provider Enumeration Date	:	12/08/2020
Last Update Date	:	12/08/2020

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