Provider Demographics
NPI:1467564377
Name:KELLY DRUG INC
Entity Type:Organization
Organization Name:KELLY DRUG INC
Other - Org Name:KELLY DRUG INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:903-569-3882
Mailing Address - Street 1:125 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:TX
Mailing Address - Zip Code:75773-2001
Mailing Address - Country:US
Mailing Address - Phone:903-569-3882
Mailing Address - Fax:903-569-3868
Practice Address - Street 1:125 E BROAD ST
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:TX
Practice Address - Zip Code:75773-2001
Practice Address - Country:US
Practice Address - Phone:903-569-3882
Practice Address - Fax:903-569-3868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
TX215563336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145183Medicaid
2097422OtherPK
4479110001Medicare NSC