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NPI Code Detail

MEDICARE: MS. GRETCHEN MARY KELLY PHARM.D

MEDICARE: MS. GRETCHEN MARY KELLY PHARM.D
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
1183500000XPharmacist056500NY

General Provider Information

NPI Number : 1841568979
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. GRETCHEN MARY KELLY PHARM.D
Provider Business Mailing Address
First Line : 135 FAIRGROUNDS MEMORIAL PKWY
Second Line : ITHACA STORE#5240
City : ITHACA
State : NY
Zip : 14850-5362
Country : US
Telephone Number : 607-277-8126
Fax Number :
Provider Business Practice Location Address
First Line : 135 FAIRGROUNDS MEMORIAL PKWY
Second Line : ITHACA STORE#5240
City : ITHACA
State : NY
Zip : 14850-5362
Country : US
Telephone Number : 607-277-8126
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/03/2011
Last Update Date : 02/08/2014

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