Provider Demographics
NPI:1194312587
Name:HASTY, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HASTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4854 LONGHILL RD STE 5
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-1500
Mailing Address - Country:US
Mailing Address - Phone:757-220-8764
Mailing Address - Fax:
Practice Address - Street 1:4854 LONGHILL RD STE 5
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-1500
Practice Address - Country:US
Practice Address - Phone:757-220-8764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-31
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202007492183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist