Provider Demographics
NPI:1528306891
Name:HAMMACK, KEILY SUZANNE
Entity type:Individual
Prefix:
First Name:KEILY
Middle Name:SUZANNE
Last Name:HAMMACK
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 1:617 US HIGHWAY 17 92 W
Mailing Address - Street 2:
Mailing Address - City:HAINES CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33844-5047
Mailing Address - Country:US
Mailing Address - Phone:863-419-1231
Mailing Address - Fax:863-421-0209
Practice Address - Street 1:617 US HIGHWAY 17 92 W
Practice Address - Street 2:
Practice Address - City:HAINES CITY
Practice Address - State:FL
Practice Address - Zip Code:33844-5047
Practice Address - Country:US
Practice Address - Phone:863-419-1231
Practice Address - Fax:863-421-0209
Is Sole Proprietor?:No
Enumeration Date:2013-01-22
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS39013183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist