Provider Demographics
NPI:1063936664
Name:BINGHAM, KELSEY (PHARMD)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:BINGHAM
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 1:6509 S 93RD EAST AVE APT D
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-1451
Mailing Address - Country:US
Mailing Address - Phone:816-206-0567
Mailing Address - Fax:
Practice Address - Street 1:315 N 193RD EAST AVE
Practice Address - Street 2:
Practice Address - City:CATOOSA
Practice Address - State:OK
Practice Address - Zip Code:74015-2862
Practice Address - Country:US
Practice Address - Phone:918-266-8837
Practice Address - Fax:918-266-1512
Is Sole Proprietor?:No
Enumeration Date:2017-07-26
Last Update Date:2017-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-17080183500000X
MO2015026125183500000X
OK16299183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist