Healthcare Provider Details

I. General information

NPI: 1639655780
Provider Name (Legal Business Name): KELLY BLYTHE-TEATS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2018
Last Update Date: 07/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 E EMPIRE ST
BLOOMINGTON IL
61704-3532
US

IV. Provider business mailing address

1701 E EMPIRE ST
BLOOMINGTON IL
61704-3532
US

V. Phone/Fax

Practice location:
  • Phone: 309-662-7004
  • Fax: 309-662-6650
Mailing address:
  • Phone: 309-662-7004
  • Fax: 309-662-6650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051293809
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: