=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083210264
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY ELIZABETH KONRAD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2020
-----------------------------------------------------
Last Update Date | 12/11/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15500 BUSTLETON AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19116-1113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-677-8593
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15500 BUSTLETON AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19116-1198
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-677-8593
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RP043235L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------