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General NPI Number Information
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NPI Number | 1629145792
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Entity Type | Organization
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Legal Business Name | KELLEY PHARMACY
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Dates
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Enumeration Date | 11/30/2006
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Last Update Date | 09/13/2007
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Provider Practice Location Address
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Address Line | 111 W HOBBS ST
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City | ROSWELL
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State | NM
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Zip | 88203-1869
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Country | US
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Telephone | 505-622-6000
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Fax | 505-623-8692
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Provider Business Mailing Address
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Address Line | PO BOX 639
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City | ROSWELL
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State | NM
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Zip | 88202-0639
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | BEAU BAUMANN
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Credential |
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Telephone | 505-623-3311
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PH00001203
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License Number State | NM
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