Healthcare Provider Details

I. General information

NPI: 1194820183
Provider Name (Legal Business Name): MARY JEAN KELLERMANN RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 SMYTH RD
MANCHESTER NH
03104-7004
US

IV. Provider business mailing address

36 BOXWOOD RD
BEDFORD NH
03110-5702
US

V. Phone/Fax

Practice location:
  • Phone: 603-624-4366
  • Fax: 603-626-6562
Mailing address:
  • Phone: 603-472-7392
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberR1129
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: