Healthcare Provider Details

I. General information

NPI: 1720413867
Provider Name (Legal Business Name): KELLY B RICHEAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2013
Last Update Date: 09/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1023 1ST AVE NE
LITTLE FALLS MN
56345-3336
US

IV. Provider business mailing address

5505 KNOLLWOOD DR
SAINT CLOUD MN
56303-4682
US

V. Phone/Fax

Practice location:
  • Phone: 320-632-1639
  • Fax:
Mailing address:
  • Phone: 563-357-9224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number121460
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: