MEDICARE: KELLY ANN SELLERS

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	13199-40	WI

General Provider Information

NPI Number	:	1578829792
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY ANN SELLERS

Provider Business Mailing Address
First Line	:	3596 E NORWICH CT
Second Line	:
City	:	ST FRANCIS
State	:	WI
Zip	:	53235-4803
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1845 N FARWELL AVE STE 200
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53202-1715
Country	:	US
Telephone Number	:	414-225-4478
Fax Number	:

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

Provider Enumeration Date	:	04/03/2012
Last Update Date	:	04/03/2012

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