Provider Demographics
NPI:1114249828
Name:MCRELL, KELLY MARY
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MARY
Last Name:MCRELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1987 ROUTE 52 STE 3
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:NY
Mailing Address - Zip Code:12754-8317
Mailing Address - Country:US
Mailing Address - Phone:845-292-8200
Mailing Address - Fax:845-292-9803
Practice Address - Street 1:1987 ROUTE 52 STE 3
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NY
Practice Address - Zip Code:12754-8317
Practice Address - Country:US
Practice Address - Phone:845-292-8200
Practice Address - Fax:845-292-9803
Is Sole Proprietor?:No
Enumeration Date:2010-02-22
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042880183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist