=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184984098
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTINA FAIRE KELLY PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2012
-----------------------------------------------------
Last Update Date | 05/24/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 937 FRANKLIN BLVD
-----------------------------------------------------
City | LEMOORE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93246-4700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-998-4499
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3223A DAUNTLESS DR
-----------------------------------------------------
City | LEMOORE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93245-2759
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-469-9494
-----------------------------------------------------
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 | 67075
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PS 45115
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 0202209469
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------