Healthcare Provider Details

I. General information

NPI: 1295874550
Provider Name (Legal Business Name): KELLY BANKS RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 S GRAND ST
MONROE LA
71202-6412
US

IV. Provider business mailing address

4800 S GRAND ST
MONROE LA
71202-6412
US

V. Phone/Fax

Practice location:
  • Phone: 318-362-3339
  • Fax: 318-362-4174
Mailing address:
  • Phone: 318-362-3339
  • Fax: 318-362-4174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1300X
TaxonomyPsychiatric Pharmacist
License Number15226
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: