Healthcare Provider Details

I. General information

NPI: 1356856348
Provider Name (Legal Business Name): MICHAEL KELLY R.PH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2017
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 E IRELAND RD
SOUTH BEND IN
46614-3448
US

IV. Provider business mailing address

9246 RED ARROW HWY
BRIDGMAN MI
49106-9591
US

V. Phone/Fax

Practice location:
  • Phone: 574-291-0740
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number26028514A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302045631
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: