Provider Demographics
NPI:1578551800
Name:M.J. KELLY PHARMACY
Entity Type:Organization
Organization Name:M.J. KELLY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:N
Authorized Official - Last Name:HOWEY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:213-622-5696
Mailing Address - Street 1:610 S BROADWAY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90014-1824
Mailing Address - Country:US
Mailing Address - Phone:213-622-5696
Mailing Address - Fax:213-622-5932
Practice Address - Street 1:610 S BROADWAY
Practice Address - Street 2:SUITE 201
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90014-1824
Practice Address - Country:US
Practice Address - Phone:213-622-5696
Practice Address - Fax:213-622-5932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY34819333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPNA348190Medicaid
0190300001Medicare ID - Type Unspecified