Basic Information
| Provider Information | |||||||||
| NPI: | 1144822263 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | DENISE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | RPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 610 JENNY WREN ST | ||||||||
| Address2: | |||||||||
| City: | VAN BUREN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729562526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4798066380 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2100 N 62ND ST | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729045163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797820606 | ||||||||
| FaxNumber: | 4797832206 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2020 | ||||||||
| LastUpdateDate: | 11/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | PD07236 | AR | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.