Provider Demographics
NPI:1316438898
Name:KELLY, LAWRENCE GERARD
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:GERARD
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 O ST APT 209
Mailing Address - Street 2:
Mailing Address - City:COZAD
Mailing Address - State:NE
Mailing Address - Zip Code:69130-1077
Mailing Address - Country:US
Mailing Address - Phone:402-699-8440
Mailing Address - Fax:
Practice Address - Street 1:2101 O ST APT 209
Practice Address - Street 2:
Practice Address - City:COZAD
Practice Address - State:NE
Practice Address - Zip Code:69130-1077
Practice Address - Country:US
Practice Address - Phone:402-699-8440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-21
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE10201183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10201OtherPHARMACY LICENSE