Provider Demographics
NPI:1235412883
Name:MCCLOSKEY, KELLIE ANN
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:ANN
Last Name:MCCLOSKEY
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 1:117 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT EPHRAIM
Mailing Address - State:NJ
Mailing Address - Zip Code:08059-1214
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1111 N HIGH ST
Practice Address - Street 2:
Practice Address - City:MILLVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08332-2528
Practice Address - Country:US
Practice Address - Phone:856-952-8219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03299100183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist