MEDICARE: DAVID KELLEY SR.

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	5302024206	MI

General Provider Information

NPI Number	:	1598175481
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID KELLEY SR.

Provider Business Mailing Address
First Line	:	2949 SHOREWOOD BLVD
Second Line	:
City	:	FORT GRATIOT
State	:	MI
Zip	:	48059-3126
Country	:	US
Telephone Number	:	810-434-9802
Fax Number	:

Provider Business Practice Location Address
First Line	:	4475 24TH AVE.
Second Line	:
City	:	FORT GRATIOT
State	:	MI
Zip	:	48059
Country	:	US
Telephone Number	:	810-385-2164
Fax Number	:	810-385-2165

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

Provider Enumeration Date	:	05/01/2014
Last Update Date	:	05/01/2014

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