MEDICARE: AMANDA KELLY

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	2009000314	MO

General Provider Information

NPI Number	:	1386084168
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA KELLY

Provider Business Mailing Address
First Line	:	9901 MANCHESTER RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63122-1915
Country	:	US
Telephone Number	:	314-919-0611
Fax Number	:

Provider Business Practice Location Address
First Line	:	9901 MANCHESTER RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63122-1915
Country	:	US
Telephone Number	:	314-919-0611
Fax Number	:

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

Provider Enumeration Date	:	06/26/2013
Last Update Date	:	06/26/2013

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Directions to “ AMANDA KELLY ” Practice Location

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