MEDICARE: KELLY HA

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	051039897	IL

General Provider Information

NPI Number	:	1215218227
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY HA

Provider Business Mailing Address
First Line	:	320 WAUKEGAN AVE
Second Line	:
City	:	HIGHWOOD
State	:	IL
Zip	:	60040-1313
Country	:	US
Telephone Number	:	847-433-5138
Fax Number	:

Provider Business Practice Location Address
First Line	:	320 WAUKEGAN AVE
Second Line	:
City	:	HIGHWOOD
State	:	IL
Zip	:	60040-1313
Country	:	US
Telephone Number	:	847-433-5138
Fax Number	:

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

Provider Enumeration Date	:	09/02/2011
Last Update Date	:	09/02/2011

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Directions to “ KELLY HA ” Practice Location

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