Provider Demographics
NPI:1447338611
Name:STETCHOCK, KELLY J (PHARMD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:STETCHOCK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 MARIEL WAY
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25311-1599
Mailing Address - Country:US
Mailing Address - Phone:304-346-9382
Mailing Address - Fax:
Practice Address - Street 1:3805 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1527
Practice Address - Country:US
Practice Address - Phone:304-926-6433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0006431183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist