Provider Demographics
NPI:1316313513
Name:HORTON, KELLY D (RPH)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:D
Last Name:HORTON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1517 FRONTAGE RD
Mailing Address - Street 2:
Mailing Address - City:LONOKE
Mailing Address - State:AR
Mailing Address - Zip Code:72086-9200
Mailing Address - Country:US
Mailing Address - Phone:501-251-7421
Mailing Address - Fax:
Practice Address - Street 1:2404 S PROMENADE BLVD
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-9080
Practice Address - Country:US
Practice Address - Phone:479-986-1101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-11
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD07722183500000X
TX56429183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist