Provider Demographics
NPI:1568744548
Name:O'GRADY, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:O'GRADY
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 1:70 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01062-1466
Mailing Address - Country:US
Mailing Address - Phone:413-586-1190
Mailing Address - Fax:413-586-1814
Practice Address - Street 1:70 MAIN ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:MA
Practice Address - Zip Code:01062-1466
Practice Address - Country:US
Practice Address - Phone:413-586-1190
Practice Address - Fax:413-586-1814
Is Sole Proprietor?:No
Enumeration Date:2011-09-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH233067183500000X
CT0011689183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist