Provider Demographics
NPI:1205017217
Name:ELY, MICHAEL JOHN (RPH)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOHN
Last Name:ELY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:346-102 ROUTE 25A
Mailing Address - Street 2:STE 102
Mailing Address - City:ROCKY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11778-8425
Mailing Address - Country:US
Mailing Address - Phone:631-744-4300
Mailing Address - Fax:631-744-3893
Practice Address - Street 1:346 ROUTE 25A
Practice Address - Street 2:STE 102
Practice Address - City:ROCKY POINT
Practice Address - State:NY
Practice Address - Zip Code:11778-8818
Practice Address - Country:US
Practice Address - Phone:631-744-4300
Practice Address - Fax:631-744-3893
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-19
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032179183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist