Provider Demographics
NPI:1356120018
Name:KELLEY, SAMUEL ROBERT (PHD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:ROBERT
Last Name:KELLEY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 E AUDUBON DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47408-9730
Mailing Address - Country:US
Mailing Address - Phone:812-606-6871
Mailing Address - Fax:
Practice Address - Street 1:410 GRAND VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46151-6123
Practice Address - Country:US
Practice Address - Phone:765-349-1138
Practice Address - Fax:765-349-2887
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-22
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26021235A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist