Provider Demographics
NPI:1366081945
Name:KELLY, NICHOLAS S (PHARMD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:S
Last Name:KELLY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1632 N FRANKLIN PL APT 512
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-3774
Mailing Address - Country:US
Mailing Address - Phone:850-449-9485
Mailing Address - Fax:
Practice Address - Street 1:1250 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WI
Practice Address - Zip Code:53024-9315
Practice Address - Country:US
Practice Address - Phone:262-375-6738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-31
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051302475183500000X
WI2018040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist