Provider Demographics
NPI:1770146482
Name:HOTALING, KELLY MARIE (PHARMD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:HOTALING
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10359 S 125TH ST
Mailing Address - Street 2:
Mailing Address - City:PAPILLION
Mailing Address - State:NE
Mailing Address - Zip Code:68046-4361
Mailing Address - Country:US
Mailing Address - Phone:308-325-4660
Mailing Address - Fax:
Practice Address - Street 1:11650 S 73RD ST
Practice Address - Street 2:
Practice Address - City:PAPILLION
Practice Address - State:NE
Practice Address - Zip Code:68046-1500
Practice Address - Country:US
Practice Address - Phone:402-597-5056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-17
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NENE14372183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NENE14372OtherLICENSE NUMBER
612165OtherNABP