Healthcare Provider Details

I. General information

NPI: 1578560892
Provider Name (Legal Business Name): MICHAEL PATRICK KELLY RPH. MBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 08/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 S 500 E SUITE 160
SALT LAKE CITY UT
84102-1959
US

IV. Provider business mailing address

127 S 500 E SUITE 160
SALT LAKE CITY UT
84102-1959
US

V. Phone/Fax

Practice location:
  • Phone: 801-587-6325
  • Fax: 801-236-8043
Mailing address:
  • Phone: 801-587-6325
  • Fax: 801-236-8043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number142148
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: