Healthcare Provider Details

I. General information

NPI: 1053755173
Provider Name (Legal Business Name): KHELLY NY II INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2013
Last Update Date: 12/24/2019
Certification Date: 12/24/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2102 EASTCHESTER RD
BRONX NY
10461-2248
US

IV. Provider business mailing address

2102 EASTCHESTER RD
BRONX NY
10461-2248
US

V. Phone/Fax

Practice location:
  • Phone: 718-684-5454
  • Fax: 718-684-5456
Mailing address:
  • Phone: 718-684-5454
  • Fax: 718-684-5456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number031875
License Number StateNV

VIII. Authorized Official

Name: MRS. BHAVNA A SHAH
Title or Position: PRESIDENT
Credential:
Phone: 732-318-9628