Healthcare Provider Details

I. General information

NPI: 1023612603
Provider Name (Legal Business Name): KELLIE MARIE VILE PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2020
Last Update Date: 11/24/2020
Certification Date: 11/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1390 N LEROY STREET
FENTON MI
48430-5310
US

IV. Provider business mailing address

1390 N LEROY ST
FENTON MI
48430-5310
US

V. Phone/Fax

Practice location:
  • Phone: 810-629-6074
  • Fax: 810-629-6125
Mailing address:
  • Phone: 810-629-6074
  • Fax: 810-629-6125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302038244
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: