Provider Demographics
NPI:1104173194
Name:ZELLERS, KELLY MAE (PHARM D)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MAE
Last Name:ZELLERS
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:MAE
Other - Last Name:ROE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1514 ESSINGTON RD
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-2866
Mailing Address - Country:US
Mailing Address - Phone:815-744-5353
Mailing Address - Fax:
Practice Address - Street 1:1514 ESSINGTON RD
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-2866
Practice Address - Country:US
Practice Address - Phone:815-744-5353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-08
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.295890183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist