Healthcare Provider Details

I. General information

NPI: 1881801397
Provider Name (Legal Business Name): JERRY B KELLY R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 E 6TH ST
PANAMA CITY FL
32401-3661
US

IV. Provider business mailing address

4333 NORTHSHORE RD
LYNN HAVEN FL
32444-4594
US

V. Phone/Fax

Practice location:
  • Phone: 850-747-6018
  • Fax: 850-747-6717
Mailing address:
  • Phone: 850-747-6018
  • Fax: 850-747-6717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License NumberPS0016008
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: