Provider Demographics
NPI:1699320986
Name:STOLL, KELLIE
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:STOLL
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 1:655 E LACKAWANNA ST
Mailing Address - Street 2:
Mailing Address - City:OLYPHANT
Mailing Address - State:PA
Mailing Address - Zip Code:18447-1924
Mailing Address - Country:US
Mailing Address - Phone:570-592-2873
Mailing Address - Fax:
Practice Address - Street 1:1201 OAK ST
Practice Address - Street 2:
Practice Address - City:PITTSTON
Practice Address - State:PA
Practice Address - Zip Code:18640-3798
Practice Address - Country:US
Practice Address - Phone:570-284-3756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP453640183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist