MEDICARE: KELLI DENISE FAIRLEY PHARM D

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	49753	FL

General Provider Information

NPI Number	:	1407106784
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLI DENISE FAIRLEY PHARM D

Provider Business Mailing Address
First Line	:	2100 NW 190TH TER
Second Line	:
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33056-2733
Country	:	US
Telephone Number	:	850-712-7223
Fax Number	:	866-788-9477

Provider Business Practice Location Address
First Line	:	2401 W ATLANTIC BLVD
Second Line	:
City	:	POMPANO BEACH
State	:	FL
Zip	:	33069-2634
Country	:	US
Telephone Number	:	954-861-5672
Fax Number	:

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

Provider Enumeration Date	:	09/14/2012
Last Update Date	:	09/14/2012

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