Provider Demographics
NPI:1962090423
Name:PEAVY, KELLI (PHARMD)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:PEAVY
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 1:609 BLUEBIRD BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT VALLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31030-5082
Mailing Address - Country:US
Mailing Address - Phone:478-825-0080
Mailing Address - Fax:
Practice Address - Street 1:609 BLUEBIRD BLVD
Practice Address - Street 2:
Practice Address - City:FORT VALLEY
Practice Address - State:GA
Practice Address - Zip Code:31030-5082
Practice Address - Country:US
Practice Address - Phone:478-825-0080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-09
Last Update Date:2021-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH028164183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist