Healthcare Provider Details

I. General information

NPI: 1578551800
Provider Name (Legal Business Name): M.J. KELLY PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 08/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 S BROADWAY SUITE 201
LOS ANGELES CA
90014-1824
US

IV. Provider business mailing address

610 S BROADWAY SUITE 201
LOS ANGELES CA
90014-1824
US

V. Phone/Fax

Practice location:
  • Phone: 213-622-5696
  • Fax: 213-622-5932
Mailing address:
  • Phone: 213-622-5696
  • Fax: 213-622-5932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHY34819
License Number StateCA

VIII. Authorized Official

Name: MRS. MARY N HOWEY
Title or Position: OWNER
Credential: RPH
Phone: 213-622-5696