MEDICARE: DR. JONATHAN ERIC KELLY PHARMD

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	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	42550	SC

General Provider Information

NPI Number	:	1649898099
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN ERIC KELLY PHARMD

Provider Business Mailing Address
First Line	:	150 ASHLEY AVE # MSC584
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29425-8907
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	150 ASHLEY AVE # MSC584
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29425-8907
Country	:	US
Telephone Number	:	678-982-1643
Fax Number	:

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

Provider Enumeration Date	:	07/13/2020
Last Update Date	:	07/13/2020

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