Provider Demographics
NPI:1730395682
Name:HERRIMAN, KELLY SUE
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:SUE
Last Name:HERRIMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6092 W B AVE
Mailing Address - Street 2:
Mailing Address - City:PLAINWELL
Mailing Address - State:MI
Mailing Address - Zip Code:49080-9735
Mailing Address - Country:US
Mailing Address - Phone:269-382-4551
Mailing Address - Fax:
Practice Address - Street 1:100 MONROE ST
Practice Address - Street 2:
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010-1363
Practice Address - Country:US
Practice Address - Phone:269-673-6749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302032580183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist