Provider Demographics
NPI:1982715017
Name:KELLY III, THOMAS PURNELL (DPH)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:PURNELL
Last Name:KELLY III
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-2127
Mailing Address - Country:US
Mailing Address - Phone:901-523-8990
Mailing Address - Fax:901-577-7455
Practice Address - Street 1:1030 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-2127
Practice Address - Country:US
Practice Address - Phone:901-523-8990
Practice Address - Fax:901-577-7455
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1924183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist