MEDICARE: DR. MICHAEL PAUL KELLY PHARM.D.

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	1835P1200X	Pharmacotherapy Pharmacist	PH00052198	WA

General Provider Information

NPI Number	:	1336142942
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL PAUL KELLY PHARM.D.

Provider Business Mailing Address
First Line	:	1830 24TH ST NE
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97301-8148
Country	:	US
Telephone Number	:	206-200-7079
Fax Number	:

Provider Business Practice Location Address
First Line	:	3750 CHEMAWA RD NE
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97305-1119
Country	:	US
Telephone Number	:	503-304-7600
Fax Number	:

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

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	03/08/2016

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