Provider Demographics
NPI:1578843298
Name:KELLEY, KENNETH CHARLES (BS)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:CHARLES
Last Name:KELLEY
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15900 SUMMERLIN RD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-3605
Mailing Address - Country:US
Mailing Address - Phone:239-481-6482
Mailing Address - Fax:
Practice Address - Street 1:15900 SUMMERLIN RD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3605
Practice Address - Country:US
Practice Address - Phone:239-481-6482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-25
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS43597183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist