Healthcare Provider Details

I. General information

NPI: 1770146482
Provider Name (Legal Business Name): KELLY MARIE HOTALING PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2019
Last Update Date: 04/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11650 S 73RD ST
PAPILLION NE
68046-1500
US

IV. Provider business mailing address

10359 S 125TH ST
PAPILLION NE
68046-4361
US

V. Phone/Fax

Practice location:
  • Phone: 402-597-5056
  • Fax:
Mailing address:
  • Phone: 308-325-4660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberNE14372
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: