Provider Demographics
NPI:1396340865
Name:PRESTAGE, KELLI NOEL
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:NOEL
Last Name:PRESTAGE
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 1:702 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38804-3734
Mailing Address - Country:US
Mailing Address - Phone:662-840-4818
Mailing Address - Fax:662-840-4816
Practice Address - Street 1:702 W MAIN ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-3734
Practice Address - Country:US
Practice Address - Phone:662-840-4818
Practice Address - Fax:662-840-4816
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-15026183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist