Provider Demographics
NPI:1447431028
Name:KELLERMANN, EDWARD PAUL (RPH)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:PAUL
Last Name:KELLERMANN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 ROUTE 110
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-4149
Mailing Address - Country:US
Mailing Address - Phone:631-271-2525
Mailing Address - Fax:
Practice Address - Street 1:325 ROUTE 110
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-4149
Practice Address - Country:US
Practice Address - Phone:631-271-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-24
Last Update Date:2007-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040206183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01562505Medicaid