Healthcare Provider Details

I. General information

NPI: 1760576011
Provider Name (Legal Business Name): KELLY PHARMACY INC KELLY PHARMACY & GIFTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 E PALMETTO
PLAIN DEALING LA
71064
US

IV. Provider business mailing address

PO BOX 188
PLAIN DEALING LA
71064-0188
US

V. Phone/Fax

Practice location:
  • Phone: 318-326-4229
  • Fax: 318-326-5903
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY.002188-IR
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: PATRICK BOGGS
Title or Position: PRESIDENT
Credential: RPH
Phone: 318-326-4229