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General NPI Number Information
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NPI Number | 1104156447
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Entity Type | Individual
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Provider Name | KELLY NEWCOM
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Gender | Female
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Dates
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Enumeration Date | 01/09/2010
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Last Update Date | 01/09/2010
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Provider Practice Location Address
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Address Line | 1223 S MAIN ST
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City | BOERNE
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State | TX
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Zip | 78006-2813
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Country | US
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Telephone | 830-249-9565
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Fax |
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Provider Business Mailing Address
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Address Line | 178 YAUPON TRL
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City | SAN ANTONIO
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State | TX
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Zip | 78256-1625
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 40754
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License Number State | TX
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