Provider Demographics
NPI:1861947079
Name:KRUEGER, KELLIE (PHARMD, RPH)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:KRUEGER
Suffix:
Gender:F
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:
Other - Last Name:STUPKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD, RPH
Mailing Address - Street 1:9885 ROCKSIDE RD STE 157
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44125-6272
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9885 ROCKSIDE RD STE 157
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44125-6272
Practice Address - Country:US
Practice Address - Phone:216-957-6337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-17
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03135718183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist