Provider Demographics
NPI:1548363005
Name:NORDSTROM, KELLY SUE (RPH)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:SUE
Last Name:NORDSTROM
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 1:3078 HWY M35
Mailing Address - Street 2:
Mailing Address - City:BARK RIVER
Mailing Address - State:MI
Mailing Address - Zip Code:49807
Mailing Address - Country:US
Mailing Address - Phone:906-786-3824
Mailing Address - Fax:
Practice Address - Street 1:325 E H ST
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-4760
Practice Address - Country:US
Practice Address - Phone:800-215-8262
Practice Address - Fax:906-779-3141
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302027309183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist