MEDICARE: KELLY MARIE COSTELLO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	26029134A	IN
2	183500000X	Pharmacist	051300725	IL

General Provider Information

NPI Number	:	1194237495
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY MARIE COSTELLO

Provider Business Mailing Address
First Line	:	2123 E COLUMBUS DR
Second Line	:
City	:	EAST CHICAGO
State	:	IN
Zip	:	46312-2831
Country	:	US
Telephone Number	:	219-397-6911
Fax Number	:

Provider Business Practice Location Address
First Line	:	2123 E COLUMBUS DR
Second Line	:
City	:	EAST CHICAGO
State	:	IN
Zip	:	46312-2831
Country	:	US
Telephone Number	:	219-397-6911
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2017
Last Update Date	:	12/17/2022

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Directions to “ KELLY MARIE COSTELLO ” Practice Location

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