Provider Demographics
NPI:1124648126
Name:WALES, KELLY ANNE (PHARMD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:WALES
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:KELLY ANNE
Other - Middle Name:WALES
Other - Last Name:JUREK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:409 CHESHAM DRIVE
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284
Mailing Address - Country:US
Mailing Address - Phone:336-202-7766
Mailing Address - Fax:
Practice Address - Street 1:3917-A WESTPOINT BOULEVARD
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-773-1013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-20
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202205435183500000X
SC13058183500000X
NC18163183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist