Healthcare Provider Details

I. General information

NPI: 1942665401
Provider Name (Legal Business Name): JOSEPH KELLOGG RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2015
Last Update Date: 12/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4840 W DESERT INN RD
LAS VEGAS NV
89102-9125
US

IV. Provider business mailing address

4840 W DESERT INN RD
LAS VEGAS NV
89102-9125
US

V. Phone/Fax

Practice location:
  • Phone: 702-248-1854
  • Fax: 702-248-7042
Mailing address:
  • Phone: 702-248-1854
  • Fax: 702-248-7042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberS010169
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: