Provider Demographics
NPI:1023612603
Name:VILE, KELLIE MARIE (PHARMD)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:MARIE
Last Name:VILE
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 1:1390 N LEROY ST
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-5310
Mailing Address - Country:US
Mailing Address - Phone:810-629-6074
Mailing Address - Fax:810-629-6125
Practice Address - Street 1:1390 N LEROY STREET
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-5310
Practice Address - Country:US
Practice Address - Phone:810-629-6074
Practice Address - Fax:810-629-6125
Is Sole Proprietor?:No
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302038244183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist