Provider Demographics
NPI:1528724416
Name:KELLY, STEPHANIE DENISE (PHARMD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DENISE
Last Name:KELLY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5750 PINELAND DR # 11
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-5300
Mailing Address - Country:US
Mailing Address - Phone:469-637-2777
Mailing Address - Fax:
Practice Address - Street 1:5750 PINELAND DR # 11
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-5300
Practice Address - Country:US
Practice Address - Phone:469-637-2777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-15
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX52462183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No183500000XPharmacy Service ProvidersPharmacist