Healthcare Provider Details

I. General information

NPI: 1376765172
Provider Name (Legal Business Name): KELLY KAY HULST RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

1000 S COLUMBIA RD
GRAND FORKS ND
58201-4032
US

IV. Provider business mailing address

761 8TH AVE NE
THOMPSON ND
58278-9330
US

V. Phone/Fax

Practice location:
  • Phone: 701-772-4875
  • Fax: 701-780-6577
Mailing address:
  • Phone: 701-599-2491
  • Fax: 701-780-6577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number4432
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: