Provider Demographics
NPI:1760015630
Name:JOLLY, KELLY LYNN (RPH)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:JOLLY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5105 LAKE WELLINGTON PKWY
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76310-1771
Mailing Address - Country:US
Mailing Address - Phone:940-636-4477
Mailing Address - Fax:
Practice Address - Street 1:405 SE ACCESS RD STE A
Practice Address - Street 2:
Practice Address - City:IOWA PARK
Practice Address - State:TX
Practice Address - Zip Code:76367-6985
Practice Address - Country:US
Practice Address - Phone:940-592-2731
Practice Address - Fax:940-592-2739
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-19
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30753183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist