Provider Demographics
NPI:1063598704
Name:MADARAS-KELLY, KARL JOSEPH (PHARMD)
Entity type:Individual
Prefix:DR
First Name:KARL
Middle Name:JOSEPH
Last Name:MADARAS-KELLY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:KARL
Other - Middle Name:JOSEPH
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12323 W DRIFTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-0025
Mailing Address - Country:US
Mailing Address - Phone:208-322-8447
Mailing Address - Fax:
Practice Address - Street 1:119A VA MEDICAL CENTER
Practice Address - Street 2:500 W FORT ST
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702
Practice Address - Country:US
Practice Address - Phone:208-422-1146
Practice Address - Fax:208-422-1147
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5076183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist