Healthcare Provider Details

I. General information

NPI: 1154478204
Provider Name (Legal Business Name): KELLY KIDZ INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 12/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 S BAY AVE
BEACH HAVEN NJ
08008-1794
US

IV. Provider business mailing address

1 S BAY AVE
BEACH HAVEN NJ
08008-1794
US

V. Phone/Fax

Practice location:
  • Phone: 609-492-9221
  • Fax: 609-492-1453
Mailing address:
  • Phone: 609-492-9221
  • Fax: 609-492-1453

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 Number28RS00627200
License Number StateNJ

VIII. Authorized Official

Name: HELEN SAMANTHA KELLY
Title or Position: OWNER
Credential: RPH
Phone: 609-492-9221