Provider Demographics
NPI:1629477583
Name:KELLEY, ROY WILLIAM
Entity Type:Individual
Prefix:MR
First Name:ROY
Middle Name:WILLIAM
Last Name:KELLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 N DEMAREE ST
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-7714
Mailing Address - Country:US
Mailing Address - Phone:559-429-3267
Mailing Address - Fax:559-429-3267
Practice Address - Street 1:1320 N DEMAREE ST
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-7714
Practice Address - Country:US
Practice Address - Phone:559-429-3267
Practice Address - Fax:559-429-3267
Is Sole Proprietor?:No
Enumeration Date:2014-08-16
Last Update Date:2014-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA 31383183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist