Healthcare Provider Details

I. General information

NPI: 1366764599
Provider Name (Legal Business Name): GARY KELLY R,PH,
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2010
Last Update Date: 02/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 S SERVICE RD
PLAINVIEW NY
11803-4100
US

IV. Provider business mailing address

45 S SERVICE RD
PLAINVIEW NY
11803-4100
US

V. Phone/Fax

Practice location:
  • Phone: 800-522-0556
  • Fax: 800-880-9022
Mailing address:
  • Phone: 800-522-0556
  • Fax: 800-880-9022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number038740
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: