MEDICARE: KELLY KIDZ INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	28RS00627200	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	2058629	OTHER	PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154478204
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KELLY KIDZ INC

Provider Business Mailing Address
First Line	:	1 S BAY AVE
Second Line	:
City	:	BEACH HAVEN
State	:	NJ
Zip	:	08008-1794
Country	:	US
Telephone Number	:	609-492-9221
Fax Number	:	609-492-1453

Provider Business Practice Location Address
First Line	:	1 S BAY AVE
Second Line	:
City	:	BEACH HAVEN
State	:	NJ
Zip	:	08008-1794
Country	:	US
Telephone Number	:	609-492-9221
Fax Number	:	609-492-1453

Authorized Official
Title or Position	:	OWNER
Name	:	HELEN SAMANTHA KELLY
Credential	:	RPH
Telephone Number	:	609-492-9221

Provider Enumeration Date	:	01/04/2007
Last Update Date	:	12/18/2018

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