Provider Demographics
NPI:1366764599
Name:KELLY, GARY (R,PH,)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:R,PH,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 S SERVICE RD
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-4100
Mailing Address - Country:US
Mailing Address - Phone:800-522-0556
Mailing Address - Fax:800-880-9022
Practice Address - Street 1:45 S SERVICE RD
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-4100
Practice Address - Country:US
Practice Address - Phone:800-522-0556
Practice Address - Fax:800-880-9022
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-15
Last Update Date:2010-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038740183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist