Healthcare Provider Details

I. General information

NPI: 1033434121
Provider Name (Legal Business Name): KELLI KILGRO CORNELIUS PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2010
Last Update Date: 03/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1514 HIGHWAY 77 LAWLEY DRUG AND MEDICAL
SOUTHSIDE AL
35907-0408
US

IV. Provider business mailing address

1514 HIGHWAY 77 LAWLEY DRUG AND MEDICAL
SOUTHSIDE AL
35907-0408
US

V. Phone/Fax

Practice location:
  • Phone: 256-413-4473
  • Fax:
Mailing address:
  • Phone: 256-413-4473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number14386
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: