Healthcare Provider Details

I. General information

NPI: 1336142942
Provider Name (Legal Business Name): MICHAEL PAUL KELLY PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 03/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3750 CHEMAWA RD NE
SALEM OR
97305-1119
US

IV. Provider business mailing address

1830 24TH ST NE
SALEM OR
97301-8148
US

V. Phone/Fax

Practice location:
  • Phone: 503-304-7600
  • Fax:
Mailing address:
  • Phone: 206-200-7079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License NumberPH00052198
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: