Healthcare Provider Details

I. General information

NPI: 1083802565
Provider Name (Legal Business Name): KELLY MAXWELL PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 10/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N WESTWOOD BLVD
POPLAR BLUFF MO
63901-3318
US

IV. Provider business mailing address

1500 N WESTWOOD BLVD
POPLAR BLUFF MO
63901-3318
US

V. Phone/Fax

Practice location:
  • Phone: 573-686-4151
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberPH-2009
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: