MEDICARE: DR. KELLY ALYSE DEBERRY 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	183500000X	Pharmacist	RPH026877	GA

General Provider Information

NPI Number	:	1356691372
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLY ALYSE DEBERRY PHARM.D.

Provider Business Mailing Address
First Line	:	8779 MCKENZIE FARM DR
Second Line	:
City	:	OOLTEWAH
State	:	TN
Zip	:	37363-5990
Country	:	US
Telephone Number	:	256-679-2018
Fax Number	:

Provider Business Practice Location Address
First Line	:	1155 BATTLEFIELD PKWY
Second Line	:
City	:	FORT OGLETHORPE
State	:	GA
Zip	:	30742-3960
Country	:	US
Telephone Number	:	762-887-6046
Fax Number	:

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

Provider Enumeration Date	:	09/17/2012
Last Update Date	:	05/13/2022

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