Provider Demographics
NPI:1720636574
Name:BALCITA, KELSEY NICOLE (PHARMD)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:NICOLE
Last Name:BALCITA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:NICOLE
Other - Last Name:LACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:500 SW RAMSEY AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-5554
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 SW RAMSEY AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5554
Practice Address - Country:US
Practice Address - Phone:541-472-7212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-26
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0016098183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist