Provider Demographics
NPI:1609156181
Name:ZELLER, KELLY (PHARMD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:ZELLER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 W JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-6622
Mailing Address - Country:US
Mailing Address - Phone:815-725-1102
Mailing Address - Fax:815-725-7500
Practice Address - Street 1:2130 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6622
Practice Address - Country:US
Practice Address - Phone:815-725-1102
Practice Address - Fax:815-725-7500
Is Sole Proprietor?:No
Enumeration Date:2011-08-28
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-286256183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL361924025130Medicaid