Provider Demographics
NPI:1417837923
Name:MCKELVIN, WILLIE III
Entity type:Individual
Prefix:
First Name:WILLIE
Middle Name:
Last Name:MCKELVIN
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1053 SW CANARY TER
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-1818
Mailing Address - Country:US
Mailing Address - Phone:561-449-4346
Mailing Address - Fax:
Practice Address - Street 1:1053 SW CANARY TER
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-1818
Practice Address - Country:US
Practice Address - Phone:561-449-4346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-04
Last Update Date:2025-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL129667183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician