Provider Demographics
NPI:1689101271
Name:CARRELLI, RYAN JOSEPH
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:JOSEPH
Last Name:CARRELLI
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 1:1141 OLIVER RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGDON VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19006-8434
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2036 S 3RD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-2643
Practice Address - Country:US
Practice Address - Phone:267-324-5347
Practice Address - Fax:267-324-5418
Is Sole Proprietor?:No
Enumeration Date:2017-05-15
Last Update Date:2017-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP445802183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist