Provider Demographics
NPI:1306459870
Name:CAULK, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CAULK
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 1:2950 COLLEGE DIVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15128 AIRLINE HWY
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70817-7307
Practice Address - Country:US
Practice Address - Phone:225-751-4415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.023562183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist