Provider Demographics
NPI:1972335792
Name:KELLEY, SAMANTHA RAE (PHARMD)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:RAE
Last Name:KELLEY
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 1:1111 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:IA
Mailing Address - Zip Code:50036-2925
Mailing Address - Country:US
Mailing Address - Phone:515-432-1304
Mailing Address - Fax:
Practice Address - Street 1:1111 8TH ST
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:IA
Practice Address - Zip Code:50036-2925
Practice Address - Country:US
Practice Address - Phone:515-432-1304
Practice Address - Fax:515-432-7136
Is Sole Proprietor?:No
Enumeration Date:2024-08-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA25130183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist